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 nurse is reviewing the plan of care for a client who is taking digoxin. Which of the following findings should the nurse monitor as an adverse effect of this medication?

• A. Hypokalemia
• B. Hypernatremia
• C. Hypertension
• D. Tachycardia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Hypokalemia is an adverse effect of digoxin. Digoxin can cause hypokalemia, which increases the risk of toxicity. Monitoring potassium levels is crucial when a client is taking digoxin. Choices B, C, and D are incorrect as hypernatremia, hypertension, and tachycardia are not directly associated with digoxin use.

3. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

4. A client with a tracheostomy shows signs of respiratory distress. What action should the nurse take immediately?

• A. Increase the suction setting on the ventilator
• B. Administer a bronchodilator
• C. Suction the tracheostomy
• D. Encourage deep breathing exercises

Correct answer: C

Rationale: The correct immediate action for a client with a tracheostomy showing signs of respiratory distress is to suction the tracheostomy. Respiratory distress in this case is often caused by a blockage, which can be quickly relieved by suctioning to clear the airway. Increasing the suction setting on the ventilator (Choice A) may not address the immediate blockage in the tracheostomy. Administering a bronchodilator (Choice B) may help with bronchoconstriction but does not address the potential blockage in the tracheostomy. Encouraging deep breathing exercises (Choice D) may not be effective in relieving the immediate respiratory distress caused by a blocked tracheostomy.

5. How should a healthcare professional assess and manage a patient with acute renal failure?

• A. Monitor urine output and administer diuretics
• B. Administer IV fluids and restrict potassium intake
• C. Monitor electrolyte levels and provide dietary education
• D. Administer potassium and restrict fluids

Correct answer: A

Rationale: In acute renal failure, it is crucial to monitor urine output to assess kidney function and fluid balance. Administering diuretics helps manage fluid levels by promoting urine production. Choice B is incorrect because administering IV fluids can worsen fluid overload in renal failure patients, and restricting potassium intake is not typically the initial approach. Choice C is not the primary intervention but is important for long-term management. Choice D is incorrect as administering potassium can be dangerous in renal failure, and restricting fluids can lead to dehydration.

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