Nursing Elites

1. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

2. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

• A. Sore throat
• B. Vertigo
• C. Fever
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

3. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

• A. Wearing clean gloves while performing a heel stick on an infant
• B. Wearing the same gloves for assessments of clients in the same room
• C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
• D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

4. A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?

• A. voiding patterns
• B. characteristics of lesions
• C. vaginal discharge
• D. prior history of varicella

Correct answer: D

Rationale: The correct answer is 'prior history of varicella.' When assessing a client with genital herpes, it is important to gather data on voiding patterns, characteristics of lesions, and vaginal discharge as these are pertinent to the disease. However, the prior history of varicella is not directly related to the current diagnosis of genital herpes. Varicella, which refers to chickenpox, is caused by the varicella-zoster virus, a different virus from the herpes simplex virus causing genital herpes.

5. How can a nurse recognize that a chronic renal failure client's AV shunt is patent?

• A. Absence of a bruit
• B. Presence of a thrill
• C. Blood return from the shunt
• D. Urine output greater than 30 ml/hr

Correct answer: B

Rationale: The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.

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