Nursing Elites

1. A client receiving IV fluids has developed phlebitis. What action should the nurse take next after removing the IV catheter?

• A. Place a warm compress over the IV site
• B. Record the findings in the client's chart
• C. Notify the client's primary care provider
• D. Insert a new IV catheter

Correct answer: A

Rationale: After removing an IV catheter due to phlebitis, the next step is to apply a warm compress over the IV site. This helps reduce inflammation and discomfort for the client. Recording the findings in the client's chart is important for documentation purposes but not the immediate next step. Notifying the client's primary care provider may be necessary depending on the severity of the phlebitis, but it is not the initial action. Inserting a new IV catheter is not appropriate until the phlebitis has resolved.

2. What is the appropriate intervention for fluid overload?

• A. Restrict fluid intake
• B. Administer diuretics
• C. Monitor vital signs
• D. All of the above

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

3. When a client with dementia frequently becomes agitated, what should the nurse prioritize investigating?

• A. Fluid and electrolyte imbalances
• B. Medication history
• C. Environmental factors
• D. Cognitive functioning

Correct answer: B

Rationale: The correct answer is to prioritize investigating the client's medication history. This is important because certain medications can contribute to agitation in clients with dementia. Understanding the medication history can help identify potential causes of agitation and guide appropriate interventions. Checking for fluid and electrolyte imbalances is important in healthcare but may not directly relate to the client's agitation. While environmental factors can influence behavior, investigating the medication history is more pertinent in this case. Cognitive functioning assessment is crucial in dementia care but may not be the priority when addressing acute agitation.

4. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2 L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

5. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

• A. Investigate medication history
• B. Investigate sensory deficits
• C. Investigate cognitive functioning
• D. Investigate for signs of infection

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

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