Nursing Elites

1. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

• A. purulent exudate
• B. warmth
• C. skin blanching
• D. bleeding

Correct answer: C

Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice A) is associated with infection, warmth (choice B) can indicate phlebitis, and bleeding (choice D) may occur if the IV catheter punctures a blood vessel.

2. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

3. A healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)

• A. Develop an acceptance of diminished strength and increased dependence on others.
• B. Spend time focusing on improving job performance.
• C. Welcome opportunities to be creative and productive.
• D. Commit to finding friendship and companionship.

Correct answer: A

Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.

4. When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?

• A. Outer skin layer becomes less resilient.
• B. Less frequent bathing may be required.
• C. Skin becomes more subject to bruising.
• D. Sweat glands become less active.

Correct answer: B

Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.

5. When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?

• A. Repeat each joint motion five times during each session.
• B. Perform the exercises quickly to save time.
• C. Focus only on the most affected joints.
• D. Assess the client's range of motion before starting.

Correct answer: A

Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.

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