Nursing Elites

1. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

• A. Erythema along the path of the vein
• B. Pitting edema at the insertion site
• C. Coolness of the client’s left forearm
• D. Pallor of the client’s left forearm

Correct answer: A

Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.

2. A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?

• A. Examine personal values about the issue.
• B. Respect the parents' decision and provide alternative treatment options.
• C. Seek a court order to proceed with the transfusion.
• D. Discuss the issue with the child.

Correct answer: A

Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.

3. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

4. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

5. A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?

• A. Label the pump with a defective equipment sticker.
• B. Unplug the pump.
• C. Obtain a replacement pump.
• D. Notify the maintenance department to fix the pump.

Correct answer: B

Rationale: Unplugging the pump is the correct initial action in this situation to prevent any potential fire hazards. Sparks when plugging in the IV pump indicate an electrical issue that can lead to a fire. By immediately unplugging the pump, the healthcare professional ensures the safety of the client and prevents any further risks. Labeling the pump with a defective equipment sticker (Choice A) is not the priority as the immediate concern is safety. Obtaining a replacement pump (Choice C) can be considered after addressing the safety issue. Notifying the maintenance department (Choice D) is important but should follow the immediate action of unplugging the pump to mitigate the risk.

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