Nursing Elites

1. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

2. What is the best dietary recommendation for a patient with chronic kidney disease?

• A. Low-protein diet
• B. High-protein diet
• C. Low-sodium diet
• D. High-sodium diet

Correct answer: C

Rationale: The correct answer is a low-sodium diet. Patients with chronic kidney disease are often advised to follow a low-sodium diet to help manage fluid retention. Excessive sodium intake can lead to fluid buildup in the body, causing complications for individuals with kidney issues. Choices A and B are incorrect because while protein intake may need to be monitored in kidney disease, the primary focus is typically on sodium restriction. Choice D is incorrect as a high-sodium diet would exacerbate fluid retention in patients with chronic kidney disease.

3. A nurse is caring for a client who has a new prescription for metformin. Which of the following findings in the client's medical history should the nurse report to the provider?

• A. History of hypertension
• B. History of polycystic ovary syndrome
• C. History of asthma
• D. History of kidney disease

Correct answer: D

Rationale: The correct answer is D, history of kidney disease. Metformin should be used with caution in clients with kidney disease due to the risk of lactic acidosis, a serious complication. Reporting this finding to the provider is crucial for assessing the appropriateness of continuing metformin therapy. Choices A, B, and C do not contraindicate the use of metformin, so they are not the priority for reporting.

4. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

5. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.

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