Nursing Elites

1. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

2. In the context of personality disorders, what is a common characteristic of a client with Borderline Personality Disorder?

• A. A need for admiration and a grandiose view of self-importance
• B. Unlawful actions and lack of empathy
• C. Fear of abandonment and impulsiveness
• D. A disregard for others with manipulative behaviors

Correct answer: C

Rationale: The correct answer is C: Fear of abandonment and impulsiveness. Individuals with Borderline Personality Disorder often exhibit intense fears of abandonment, engage in impulsive behaviors such as self-harm or substance abuse, and struggle with unstable relationships. Choices A, B, and D do not align with the characteristic features commonly associated with Borderline Personality Disorder. A need for admiration and grandiosity (Choice A) is more characteristic of Narcissistic Personality Disorder. Unlawful actions and lack of empathy (Choice B) are more typical of Antisocial Personality Disorder. A disregard for others with manipulative behaviors (Choice D) is often seen in individuals with traits of Histrionic or Antisocial Personality Disorders.

3. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

• A. Demonstrate how to use the spirometer
• B. Set a realistic postoperative goal
• C. Determine the reasons why the client is refusing
• D. Request that a respiratory therapist discuss the technique

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

4. What are the key considerations when administering opioid analgesics to a patient in pain?

• A. Monitoring for respiratory depression
• B. Administering opioid antagonist if needed
• C. Assessing respiratory rate and pain level before administration
• D. Monitoring the patient's level of consciousness

Correct answer: A

Rationale: The correct key consideration when administering opioid analgesics to a patient in pain is monitoring for respiratory depression. Opioids can lead to respiratory depression, making it crucial to carefully monitor the patient's breathing. Administering an opioid antagonist is not a key consideration during the administration of opioids; it is used to reverse opioid effects in cases of overdose, not as a routine practice. Assessing respiratory rate and pain level before administration is important but not the key consideration compared to monitoring for respiratory depression. Monitoring the patient's level of consciousness is also essential but not as critical as monitoring for respiratory depression when administering opioids.

5. How should a healthcare professional assess a patient's pain who is non-verbal?

• A. Looking for changes in vital signs that may indicate pain
• B. Using alternative methods like touch or distraction
• C. Using a pain scale appropriate for non-verbal patients
• D. Observing for facial expressions or other non-verbal cues

Correct answer: A

Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.

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