Nursing Elites

1. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

2. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Mashed potatoes
• C. Orange slices
• D. Soft-cooked eggs

Correct answer: C

Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.

4. A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?

• A. Canned soup
• B. Fresh fruit
• C. Processed meats
• D. Frozen meals

Correct answer: B

Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.

5. A nurse is preparing to transfer a client from a bed to a chair. The client can bear partial weight and has upper body strength. What device should the nurse use?

• A. Mechanical lift
• B. Gait belt
• C. Slide board
• D. Stand-assist lift

Correct answer: D

Rationale: A stand-assist lift is the correct choice in this scenario. This device is suitable for clients who can bear partial weight and have upper body strength, as it allows them to actively participate in the transfer process. A mechanical lift is typically used for clients who are non-weight bearing or have limited mobility. A gait belt is used for providing support and stability during walking or transferring short distances. A slide board is used for transferring clients who are unable to bear weight and need assistance moving from one surface to another.

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