Nursing Elites

1. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

• A. Keep the client's extremities cold
• B. Check for strength and symmetry of peripheral pulses
• C. Keep the client's legs elevated
• D. Monitor for any constrictions, such as clothes or covers that are too tight around the legs

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

2. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

3. In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:

• A. Will you briefly summarize your point because others need time as well?
• B. Your behavior is obnoxious and drains the group.
• C. I am so frustrated with your behavior.
• D. To ignore the behavior and allow him to vent

Correct answer: A

Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.

4. 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.

5. Which type of cell is responsible for producing antibodies in the immune system?

• A. B lymphocytes
• B. T lymphocytes
• C. Macrophages
• D. Neutrophils

Correct answer: A

Rationale: The correct answer is A: B lymphocytes. B lymphocytes (B cells) are a crucial part of the adaptive immune system. They produce antibodies, which are proteins that specifically target and neutralize pathogens such as bacteria and viruses. T lymphocytes (choice B) are involved in cell-mediated immunity rather than antibody production. Macrophages (choice C) are phagocytic cells that engulf and digest pathogens but do not produce antibodies. Neutrophils (choice D) are a type of white blood cell that primarily function in the innate immune response by phagocytosing pathogens.

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