Nursing Elites

1. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

• A. Obtain a specimen for culture.
• B. Apply a warm compress.
• C. Administer analgesics.
• D. Discontinue the infusion.

Correct answer: D

Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.

2. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

3. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN?

• A. Creating a plan of care for a client who is recovering following a stroke.
• B. Assessing a pressure injury on a client who is on bed rest.
• C. Providing nasopharyngeal suctioning for a client who has pneumonia.
• D. Teaching a client who has asthma to use a metered-dose inhaler.

Correct answer: C

Rationale: The correct answer is providing nasopharyngeal suctioning for a client who has pneumonia. This task falls within the practical nurse's scope of practice, as it involves direct patient care and basic interventions. Creating a plan of care for a client recovering from a stroke involves critical thinking and comprehensive assessment, which are typically responsibilities of registered nurses. Assessing a pressure injury requires specialized wound care knowledge, often performed by wound care specialists or registered nurses with wound care training. Teaching a client to use a metered-dose inhaler involves patient education and requires a thorough understanding of asthma management, making it more suitable for a registered nurse.

4. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

5. A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse’s priority?

• A. Ensure that the client signs the consent form.
• B. Lock the client’s valuables in a secure location.
• C. Verify the client’s lab values in the medical record.
• D. Administer the prescribed preoperative sedative.

Correct answer: A

Rationale: The nurse’s priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client’s right to make decisions about their care.

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