Nursing Elites

1. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

• A. Apply a cold compress to the site
• B. Notify the provider immediately
• C. Remove the IV catheter and restart it in another location
• D. Monitor the site for signs of infection

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

2. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

3. A nurse is reviewing the medical record of a client with dementia who frequently becomes agitated. What should the nurse prioritize?

• A. Investigate the client's fluid and electrolyte balance
• B. Investigate the client's recent medication changes
• C. Investigate recent changes in cognitive functioning
• D. Investigate the client's psychosocial environment

Correct answer: B

Rationale: The correct answer is to investigate the client's recent medication changes. In a client with dementia who frequently becomes agitated, medication changes can often be a significant factor contributing to their behavior. Checking recent medication changes can help identify if any specific medication is causing or exacerbating the agitation. Choice A about fluid and electrolyte balance is less likely to be the priority unless there are specific indications in the medical record. Choice C, investigating recent changes in cognitive functioning, may be important but addressing the agitation first is a more immediate concern. Choice D, investigating the client's psychosocial environment, is also important but may not directly address the immediate cause of the agitation as medication changes could.

4. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse take?

• A. Use the Z-track method to administer the medication.
• B. Use a 1.5-inch needle to administer the medication.
• C. Use the deltoid muscle for the injection.
• D. Administer the injection at a 90° angle.

Correct answer: A

Rationale: The Z-track method should be used to administer IM injections in obese clients to prevent medication from leaking into subcutaneous tissue. Using a longer needle (1.5 inches) ensures that the medication reaches the muscle mass adequately. Choice C is incorrect because the deltoid muscle is not ideal for IM injections in obese clients due to inadequate muscle mass. Administering the injection at a 90° angle (perpendicular to the skin) is recommended for IM injections to ensure proper delivery into the muscle.

5. A client with diabetes is experiencing hyperglycemia. What is the nurse's priority?

• A. Administer insulin
• B. Encourage the client to exercise to lower blood glucose
• C. Encourage the client to drink water
• D. Administer glucagon

Correct answer: A

Rationale: The correct answer is to administer insulin. In hyperglycemia, there is an excess of glucose in the blood, which needs to be lowered. Insulin is the primary medication used to lower blood glucose levels by facilitating the uptake of glucose into cells. Encouraging the client to exercise may further increase blood glucose levels due to the release of stress hormones, so it is not the priority. While staying hydrated is important, it will not directly address the high blood glucose levels seen in hyperglycemia. Glucagon is used to treat severe hypoglycemia, not hyperglycemia, so it is not the priority in this situation.

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