Nursing Elites

1. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

2. A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

• A. Figs
• B. Broccoli
• C. Stewed tomatoes
• D. Skim milk

Correct answer: D

Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.

3. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

4. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

• A. Hold the tube feeding and notify the provider
• B. Administer the tube feeding as scheduled
• C. Irrigate the tube with diet cola soda
• D. Apply intermittent suction to the feeding tube

Correct answer: A

Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.

5. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?

• A. Obtain a 12-lead EKG
• B. Place the client in high Fowler's position
• C. Lower the oxygen rate
• D. Take baseline vital signs

Correct answer: C

Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.

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