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 nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

3. A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?

• A. Measure the residual gastric volume
• B. Verify tube placement
• C. Flush the tube with 100 mL of water
• D. Administer the feeding in small boluses

Correct answer: B

Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

• A. Natural immunity
• B. Acquired immunity
• C. Passive immunity
• D. Cell-mediated immunity

Correct answer: B

Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

5. A nurse is caring for a client who is receiving continuous enteral feedings. What finding indicates intolerance to the feeding?

• A. Weight gain
• B. Nausea
• C. Constipation
• D. Elevated heart rate

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain is not typically associated with intolerance to enteral feedings; instead, it may indicate other issues such as fluid retention. Constipation is also not a direct indicator of intolerance to enteral feedings. While an elevated heart rate can occur for various reasons, it is less specific to enteral feeding intolerance compared to nausea.

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