Nursing Elites

1. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

2. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

• A. Record usual eating patterns
• B. Evaluate for muscle cramping
• C. Document abdominal girth
• D. Elevate both legs on pillows

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

3. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

• A. Take all prescribed antibiotics as directed.
• B. Avoid crowded places and people who are sick.
• C. Wash hands frequently and practice good hygiene.
• D. Keep the surgical site clean and dry.

Correct answer: C

Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.

4. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?

• A. Document the finding and continue to monitor.
• B. Apply warm compresses to the stoma.
• C. Notify the healthcare provider immediately.
• D. Encourage the client to ambulate.

Correct answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

5. A dispersion consists of a solute dispersed through a dispersing vehicle. Which of the following dispersions is a liquid for topical application that contains insoluble solids or liquids?

• A. Ointment
• B. Lotion
• C. Paste
• D. Gel

Correct answer: B

Rationale: The correct answer is B, 'Lotion.' A lotion is a liquid dispersion that contains insoluble solids or liquids for topical application. Ointments are more semi-solid and occlusive, pastes are thicker and contain higher concentrations of solids, and gels have a jelly-like consistency due to their three-dimensional network structure. Therefore, among the options, a lotion is the most suitable choice for containing insoluble solids or liquids for topical application.

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