Nursing Elites

1. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?

• A. Bruising at the IV site
• B. Edema at the IV site
• C. Warmth along the IV site
• D. Pallor at the IV site

Correct answer: B

Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.

2. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?

• A. Administer prescribed antibiotics
• B. Initiate seizure precautions
• C. Identify the client's needs
• D. Place the client in isolation

Correct answer: C

Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.

3. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?

• A. Wear non-sterile gloves
• B. Apply sterile gloves over non-sterile gloves
• C. Change gloves if the sterile solution splashes onto the sterile field
• D. Cover the sterile field with a sterile drape

Correct answer: C

Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.

4. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

5. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?

• A. Dissolve crushed tablet medications in tap water
• B. Administer all medications together
• C. Flush the NG tube with 60 mL of water before each medication
• D. Dissolve medications separately and flush with sterile water

Correct answer: D

Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.

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