Nursing Elites

1. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

2. A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor daily fluid intake
• B. Monitor blood glucose levels
• C. Measure intake and output
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.

3. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

4. A client has expressive aphasia following a stroke. Which of the following methods should be used when communicating with the client?

• A. Speak slowly
• B. Provide written instructions
• C. Use a picture board
• D. Write on a whiteboard

Correct answer: C

Rationale: When communicating with a client who has expressive aphasia, using a picture board is an effective method as it provides an alternative means of communication. Option A, speaking slowly, may not improve understanding for someone with expressive aphasia. Option B, providing written instructions, may also be challenging for individuals with this condition. Option D, writing on a whiteboard, may not be as helpful as using a picture board in facilitating communication for a client with expressive aphasia.

5. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

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