Nursing Elites

1. What are the key nursing considerations for a patient with a central venous catheter?

• A. Maintain sterility during dressing changes
• B. Change the dressing weekly
• C. Monitor blood pressure and fluid balance
• D. Monitor the catheter site for infection

Correct answer: A

Rationale: The correct answer is A: Maintain sterility during dressing changes. It is crucial to maintain sterility during dressing changes for patients with central venous catheters to prevent infections. Changing the dressing weekly (Choice B) is not frequent enough to prevent infections effectively. Monitoring blood pressure and fluid balance (Choice C) is important for overall patient care but not specific to central venous catheter management. While monitoring the catheter site for infection (Choice D) is important, the key consideration is to prevent infections through proper sterile techniques during dressing changes.

2. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

• A. Assess mobility
• B. Monitor vital signs
• C. Provide pain relief
• D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

3. How should a healthcare professional manage a patient with suspected infection?

• A. Monitor vital signs and administer antibiotics
• B. Check for fever and monitor white blood cell count
• C. Assess for pain and check for localized swelling
• D. Monitor for chills and administer fluids

Correct answer: A

Rationale: Correct answer: When managing a patient with suspected infection, it is crucial to monitor vital signs like temperature, heart rate, blood pressure, and respiratory rate to assess the severity of the infection. Administering antibiotics is also essential to treat the infection. Choice B is incorrect because while checking for fever and monitoring white blood cell count are important, they alone are not sufficient to manage the patient. Choice C focuses on assessing pain and localized swelling, which are important but not primary in managing suspected infection. Choice D mentions monitoring for chills and administering fluids, which are not the primary interventions for managing a suspected infection.

4. What is the priority when managing a client with a chest tube postoperatively?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.

5. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

• A. Weight gain.
• B. Dry mouth.
• C. Sedation.
• D. Shuffling gait.

Correct answer: D

Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.

Similar Questions