Nursing Elites

1. What is the most important nursing action when a patient has a central line?

• A. Monitor for infection
• B. Monitor the central line dressing
• C. Monitor for redness
• D. Monitor for swelling

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

2. What is the first action to take when a patient experiences a seizure?

• A. Protect the patient from injury
• B. Administer oxygen
• C. Administer IV fluids
• D. Administer anti-seizure medication

Correct answer: A

Rationale: The first action to take when a patient experiences a seizure is to protect the patient from injury. This is crucial to prevent harm during the seizure. Administering oxygen, IV fluids, or anti-seizure medication may be necessary based on the patient's condition, but ensuring their safety by removing harmful objects, cushioning their head, and keeping the area clear is the immediate priority. Administering oxygen, IV fluids, or medication would come after ensuring the patient's safety.

3. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

• A. I can give you information about respite care if you are interested.
• B. You should consider taking a sleeping pill before bed each night.
• C. It must be difficult taking care of someone who is terminally ill.
• D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

4. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle modifications. Which of the following instructions should be included?

• A. Sleep with the head of the bed elevated.
• B. Avoid drinking fluids with meals.
• C. Eat three large meals each day.
• D. Lie down after eating.

Correct answer: B

Rationale: The correct instruction for a client with GERD is to avoid drinking fluids with meals. This is because consuming fluids while eating can exacerbate reflux symptoms by increasing stomach distension and contributing to the reflux of stomach contents into the esophagus. Option A is incorrect as elevating the head of the bed can help prevent reflux during sleep, not while drinking fluids. Option C is incorrect as consuming three large meals a day can worsen GERD symptoms due to increased gastric distension. Option D is incorrect as lying down after eating can also worsen GERD symptoms by promoting the reflux of stomach contents into the esophagus.

5. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hours following surgery.
• B. Give cromolyn nebulizer solution every 6 hours.
• C. Apply a warm compress to the operative site every 4 hours.
• D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

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