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. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:

• A. Positions the irrigating solution bag 30 inches below the stoma
• B. Uses an open system for irrigation
• C. Irrigates the colostomy twice a day
• D. Cleans the stoma with harsh chemicals

Correct answer: A

Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.

3. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Secure the tube to the client's gown.
• C. Check the placement of the tube by auscultation.
• D. Irrigate the tube with normal saline every shift.

Correct answer: A

Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.

4. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

• A. Carry a client's soiled linens out of the room in a mesh linen bag
• B. Place a client who has tuberculosis in a room with negative-pressure airflow
• C. Provide disposable plates and utensils for a client who is HIV-positive
• D. Dispose of a client's blood-saturated dressing in a biohazard bag

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.

5. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

• A. Delegates assessment of lung sounds to nursing assistive personnel
• B. Becomes solely responsible for modifying activities of daily living
• C. Consults physical therapy for strengthening exercises in the extremities
• D. Involves respiratory therapy for altered breathing from severe anxiety levels

Correct answer: C

Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.

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