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. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

• A. That indicates you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are dilating and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

3. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?

• A. “My baby loved to play with the crib gym, but I took it out of the crib.”
• B. “I just bought a firm mattress so my baby will sleep better.”
• C. “My baby really likes sleeping on the fluffy pillow we just got.”
• D. “I put the baby’s car seat on the table after I put him in it.”

Correct answer: A

Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.

4. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

• A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
• B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
• C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
• D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Correct answer: A

Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.

5. When assessing a client's skin turgor, a nurse should:

• A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
• B. Check skin elasticity on the back of the hand
• C. Press on the skin over the abdomen
• D. Measure skin turgor on the lower leg

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

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