Nursing Elites

1. A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention?

• A. Providing cholesterol screening
• B. Teaching about a healthy diet
• C. Providing information about antihypertensive medications
• D. Developing a list of cardiac rehabilitation programs

Correct answer: B

Rationale: Teaching about a healthy diet is considered a primary prevention activity. Primary prevention aims to prevent the onset of a disease or health problem. Educating individuals on healthy lifestyle choices, such as diet modification, falls under primary prevention. Providing cholesterol screening (choice A) is a secondary prevention measure aimed at early detection. Offering information about antihypertensive medications (choice C) falls under secondary prevention, focusing on controlling risk factors. Developing a list of cardiac rehabilitation programs (choice D) is part of tertiary prevention, focusing on rehabilitation and improving outcomes post-disease onset.

2. A client is receiving discharge instructions for using a walker. Which statement indicates an understanding of the teaching?

• A. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
• B. I will avoid using the walker on uneven surfaces.
• C. I will use the walker on stairs for added support.
• D. I will not need to make any changes to my home environment.

Correct answer: A

Rationale: The correct answer is A because hiring someone to trim low-hanging branches over stairs ensures home safety and reflects an understanding of walker use. This action indicates the client's awareness of potential hazards and the importance of a safe environment for walker use. Choice B is incorrect as avoiding uneven surfaces is a general safety precaution but does not directly relate to walker use and does not demonstrate an understanding of the teaching. Choice C is incorrect because using a walker on stairs is not recommended due to safety concerns such as balance and fall risks. Choice D is incorrect as making no changes to the home environment may pose safety risks when using a walker, showing a lack of understanding regarding safety precautions needed for walker use.

3. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?

• A. Remove the restraints every 4 hours.
• B. Attach the restraints securely to the side of the client's bed.
• C. Apply the restraints to allow as little movement as possible.
• D. Allow room for two fingers to fit between the client's skin and the restraints.

Correct answer: D

Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.

4. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

5. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

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