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 warm. What should the nurse do?

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

Correct answer: B

Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.

2. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

• A. Reassure the client of the surgeon's skill
• B. The surgeon will answer your questions before surgery
• C. Tell the client surgery is necessary
• D. Encourage the client to seek a second opinion

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

3. A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the IV infusion
• C. Apply a cold compress
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

4. A client is being taught how to use a cane. Which instruction should the nurse include?

• A. Use the cane on the stronger side
• B. Use the cane on the weaker side
• C. Ensure the cane has a rubber tip
• D. Hold the cane 1-2 inches from the ground

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.

5. A healthcare professional is reviewing a client's medical history and identifies an increased risk for infections. What risk factor should the healthcare professional include?

• A. Frequent handwashing
• B. Increased mobility
• C. High blood pressure
• D. Chronic conditions

Correct answer: D

Rationale: The correct answer is D: Chronic conditions. Chronic conditions, such as diabetes or immune suppression, can compromise the immune system, making individuals more susceptible to infections. Frequent handwashing (Choice A) is actually a protective measure against infections. Increased mobility (Choice B) and high blood pressure (Choice C) are not directly associated with an increased risk for infections.

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