Nursing Elites

1. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

• A. Administer an anti-inflammatory medication
• B. Discontinue the IV and notify the provider
• C. Apply a cold compress over the IV site
• D. Increase the IV flow rate to prevent dehydration

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

2. 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.

3. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer oxytocin
• B. Perform fundal massage
• C. Administer IV fluids
• D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

4. What are the risk factors for developing Type 2 diabetes?

• A. Obesity, sedentary lifestyle, and poor diet
• B. Age, gender, and family history
• C. Smoking, alcohol consumption, and hypertension
• D. Frequent exercise and low-carbohydrate diet

Correct answer: A

Rationale: The correct answer is A: Obesity, sedentary lifestyle, and poor diet are established risk factors for developing Type 2 diabetes. Obesity puts extra pressure on the body's ability to properly control blood sugar levels. A sedentary lifestyle contributes to weight gain and insulin resistance. Poor diet, especially one high in processed foods and sugary beverages, can also increase the risk of developing Type 2 diabetes. Choices B, C, and D are incorrect because age, gender, family history, smoking, alcohol consumption, and hypertension can impact overall health but are not the primary risk factors for Type 2 diabetes.

5. Which intervention is most important for a client with rheumatoid arthritis?

• A. Massage inflamed joints with creams and oils
• B. Provide support to flexed joints with pillows and pads
• C. Position the client on their abdomen several times a day
• D. Assist with heat application and range of motion exercises

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

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