Nursing Elites

1. 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.

2. A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?

• A. Deltoid
• B. Ventrogluteal
• C. Rectus femoris
• D. Dorsogluteal

Correct answer: B

Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.

3. A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?

• A. I will soak my feet in hot water daily
• B. I will wear shoes at all times
• C. I will cut my toenails in a rounded shape
• D. I will apply lotion between my toes after bathing

Correct answer: B

Rationale: The correct answer is B: 'I will wear shoes at all times.' This statement demonstrates an understanding of foot care for a client with diabetes. Wearing shoes at all times helps protect the feet, reducing the risk of injury and complications such as wounds or infections. Option A is incorrect because soaking feet in hot water can lead to skin dryness and increase the risk of burns or injury for individuals with diabetes. Option C is incorrect as cutting toenails in a rounded shape can cause ingrown toenails and potential infections. Option D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

4. A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?

• A. Health literacy, income, gender
• B. Eye contact, personal space, touch
• C. Physical activity, ethnicity, eye contact
• D. Body language, facial expressions, religion

Correct answer: B

Rationale: The correct answer is B: Eye contact, personal space, and touch are cultural variables that can influence healthcare interactions. These factors vary across cultures and can impact how individuals perceive communication and interactions. Choices A, C, and D include elements that are not specifically cultural variables affecting communication and interactions in the same way as eye contact, personal space, and touch.

5. A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?

• A. Bladder distention
• B. Bladder spasms
• C. Hematuria
• D. Increased urine output

Correct answer: A

Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.

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