Nursing Elites

1. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

• A. The client reports pain at the IV site
• B. The client’s blood pressure is elevated
• C. The client has swelling at the IV site
• D. The client’s heart rate is irregular

Correct answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

2. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

• A. On the left side of the bed facing the foot of the bed.
• B. On the right side of the bed facing the head of the bed.
• C. Perpendicular to the bed on the right side.
• D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.

3. The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

• A. Standing on the woman's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the woman's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the woman, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the woman, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: The correct answer is B. Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness. Choices A, C, and D are incorrect because they do not provide the optimal support and security needed for a client with right-sided weakness. Standing on the weak side and holding the gait belt from the back is the most effective way to assist the client while minimizing the risk of falls.

4. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

5. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• A. Tell the UAP to use a larger cuff at the next scheduled assessment.
• B. Reassess the client's blood pressure using a larger cuff.
• C. Have the unit educator review this procedure with the UAPs.
• D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.

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