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. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

3. A client has undergone a myelogram, and a nurse is providing post-procedure care. Which action should be included in the nursing care plan?

• A. Encourage ambulation after the procedure
• B. Maintain the prone position for 12 hours
• C. Evaluate the client's distal pulses on the affected side
• D. Encourage oral fluid intake

Correct answer: C

Rationale: The correct action to include in the nursing care plan for a client post-myelogram is to evaluate the client's distal pulses on the affected side. This is crucial to assess circulation and detect any potential complications such as impaired blood flow or vascular issues. Encouraging ambulation after the procedure (Choice A) is not typically recommended immediately post-myelogram, as the client may need to rest. Maintaining the prone position for 12 hours (Choice B) is an outdated practice and is no longer part of standard care post-myelogram. Encouraging oral fluid intake (Choice D) is generally beneficial for hydration but is not a specific priority related to post-myelogram care.

4. What are the key nursing assessments for a patient receiving enteral feeding?

• A. Monitor gastric residual volume and check for abdominal distension
• B. Ensure the correct placement of the feeding tube
• C. Assess for signs of dehydration and electrolyte imbalances
• D. Elevate the head of the bed to prevent aspiration

Correct answer: A

Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.

5. A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

• A. A client who is NPO and has dry mucous membranes
• B. A client with rotavirus who has been vomiting
• C. A client who has a urinary catheter and cloudy urine
• D. A client who has pneumonia and a new onset of confusion

Correct answer: D

Rationale: The correct answer is D because a client with pneumonia and a new onset of confusion needs immediate evaluation for changes in neurological status. This could indicate a decline in respiratory status or potential complications such as hypoxia or sepsis. Option A, a client who is NPO and has dry mucous membranes, may need intervention but does not indicate an acute change in condition. Option B, a client with rotavirus who has been vomiting, requires assessment and intervention but does not pose an immediate threat to life. Option C, a client with a urinary catheter and cloudy urine, may indicate a urinary tract infection but does not require immediate attention compared to the client with new onset confusion and pneumonia.

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