Nursing Elites

1. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

• A. Apply a cold compress
• B. Notify the physician immediately
• C. Apply a warm compress
• D. Administer anti-inflammatory medication

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

2. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?

• A. Apply heat to the affected knee
• B. Avoid placing pillows under the knee
• C. Avoid moving the knee for 2-3 days
• D. Apply ice to the affected knee for 24-48 hours

Correct answer: D

Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.

3. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

• A. Ignore the behavior
• B. Reassign the AP
• C. Report the behavior to the manager
• D. Discuss this behavior with the AP while reinforcing expectations

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.

4. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?

• A. Take your blood pressure after eating
• B. Sit quietly for 5 minutes before taking your blood pressure
• C. Use a blood pressure cuff that is too small
• D. Take your blood pressure while standing

Correct answer: B

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.

5. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

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