Nursing Elites

1. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

2. What is the best way to monitor for infection in a patient with a central line?

• A. Check the central line site daily
• B. Monitor the patient's vital signs
• C. Check the central line dressing every other day
• D. Check for signs of sepsis

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administration.
• B. Administer the medication intramuscularly.
• C. Inject the medication into the client's abdomen.
• D. Inject the medication into the deltoid muscle.

Correct answer: C

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.

4. A healthcare provider is assessing a client who has acute pancreatitis. Which of the following laboratory results should the healthcare provider expect to be elevated?

• A. Serum sodium.
• B. Serum calcium.
• C. Serum glucose.
• D. Serum amylase.

Correct answer: D

Rationale: Serum amylase levels are typically elevated in clients with acute pancreatitis as it is an enzyme released by the pancreas. Elevated serum sodium, calcium, or glucose levels are not typically associated with acute pancreatitis. Therefore, choices A, B, and C are incorrect.

5. What is the most important nursing action when a patient has a central line?

• A. Monitor for infection
• B. Monitor the central line dressing
• C. Monitor for redness
• D. Monitor for swelling

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

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