Nursing Elites

1. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

• A. In the afternoon
• B. As soon as the client awakens in the morning
• C. Before bedtime
• D. Immediately after lunch

Correct answer: B

Rationale: The correct answer is B: 'As soon as the client awakens in the morning.' Sputum specimens should be collected early in the morning to obtain a concentrated sample. This timing ensures that the specimen is less diluted, providing a more accurate analysis. Choices A, C, and D are incorrect as they do not align with the optimal timing for collecting a sputum specimen, which is in the morning.

2. 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.

3. What is the most appropriate next step when a client with an NG tube attached to low suctioning becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client on their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water. When a client with an NG tube attached to low suctioning becomes nauseated and there is a decrease in the flow of gastric secretions, it indicates a possible blockage in the tube. Irrigating the tube with sterile water can help clear the blockage, allowing for proper suctioning and relieving the client's nausea. Increasing the suction pressure (Choice A) can further worsen the issue by potentially causing harm to the client. Turning the client on their side (Choice C) may not address the underlying problem of tube blockage. Replacing the NG tube with a new one (Choice D) should only be considered if other interventions, like irrigation, fail to clear the blockage.

4. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

• A. High workload
• B. Limited knowledge on the subject
• C. Poor lighting
• D. Limited space in the learning area

Correct answer: C

Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.

5. What are the common causes of postoperative pain and how should it be managed?

• A. Surgical incision and muscle tension
• B. Nerve damage and wound complications
• C. Hypotension and respiratory issues
• D. Infection at the incision site

Correct answer: A

Rationale: Postoperative pain is commonly caused by the surgical incision and muscle tension. The correct answer is A. Surgical incisions cause tissue damage, triggering pain responses. Muscle tension can result from factors like positioning during surgery or guarding due to pain. Managing postoperative pain caused by surgical incisions and muscle tension involves the use of analgesics to alleviate discomfort. Choices B, C, and D are incorrect. Nerve damage and wound complications may also cause pain but are not as common as surgical incisions and muscle tension. Hypotension and respiratory issues are not direct causes of postoperative pain. Infection at the incision site can lead to pain, but it is a specific complication rather than a common cause of postoperative pain.

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