Nursing Elites

1. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

2. What are the key differences between systolic and diastolic heart failure?

• A. Systolic: Reduced ejection fraction; Diastolic: Preserved ejection fraction
• B. Systolic: Preserved ejection fraction; Diastolic: Reduced ejection fraction
• C. Systolic: Right-sided heart failure; Diastolic: Left-sided heart failure
• D. Systolic: Pulmonary congestion; Diastolic: Systemic congestion

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.

3. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

4. What are the signs and symptoms of a potential infection?

• A. Fever, chills, and increased heart rate
• B. Increased white blood cell count and fever
• C. Shortness of breath and confusion
• D. Sweating and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Fever, chills, and increased heart rate are classic signs of an infection. These symptoms indicate the body's response to an invading pathogen. Choice B, 'Increased white blood cell count and fever,' is not a primary symptom that a person would typically notice themselves, and white blood cell count needs to be tested. Choice C, 'Shortness of breath and confusion,' may indicate other conditions like heart or lung issues rather than a general infection. Choice D, 'Sweating and low blood pressure,' are not specific to infections and can be caused by various factors like heat or dehydration.

5. What is the best dietary recommendation for a patient with chronic kidney disease?

• A. Low-protein diet
• B. High-protein diet
• C. Low-sodium diet
• D. High-sodium diet

Correct answer: A

Rationale: The correct answer is a low-protein diet for a patient with chronic kidney disease. In chronic kidney disease, the kidneys may have difficulty filtering waste products from protein metabolism, leading to a buildup of toxins in the body. Therefore, reducing protein intake can help lessen the workload on the kidneys. Choices B, C, and D are incorrect. A high-protein diet would increase the workload on the kidneys, while a low-sodium diet is beneficial for conditions like hypertension or heart failure but not specifically targeted for chronic kidney disease. A high-sodium diet can worsen fluid retention and hypertension in patients with kidney disease.

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