Nursing Elites

1. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

• A. Natural immunity
• B. Acquired immunity
• C. Passive immunity
• D. Cell-mediated immunity

Correct answer: B

Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

2. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?

• A. Rest in bed for long periods
• B. Use sequential compression devices
• C. Avoid leg exercises
• D. Keep legs crossed

Correct answer: B

Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.

3. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

4. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

5. A healthcare professional is preparing to administer multiple medications to a client with dysphagia. What action should the healthcare professional take?

• A. Offer the medications with a full glass of water
• B. Crush the medications and mix them together
• C. Provide the medications through a straw
• D. Mix the medications with applesauce

Correct answer: C

Rationale: Clients with dysphagia have difficulty swallowing, so providing medications through a straw can help control the flow and prevent aspiration. Offering medications with a full glass of water (Choice A) may increase the risk of aspiration. Crushing medications and mixing them together (Choice B) can alter the medication's effectiveness or cause adverse effects. Mixing medications with applesauce (Choice D) may also present a choking hazard for clients with dysphagia.

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