Nursing Elites

1. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?

• A. Shave the hair at the insertion site.
• B. Cleanse the site with povidone-iodine.
• C. Wear sterile gloves when changing the dressing.
• D. Change the IV site every 48 to 72 hours.

Correct answer: D

Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.

2. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

• A. Encourage the client to increase fluid intake.
• B. Suction the client every 2 hours.
• C. Perform chest physiotherapy every 8 hours.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

3. A healthcare provider is teaching a client who has a new prescription for levothyroxine. Which of the following instructions should the healthcare provider include?

• A. Take this medication with meals.
• B. Take this medication at the same time every day.
• C. Report any chest pain to your healthcare provider immediately.
• D. Take an antacid if indigestion occurs.

Correct answer: B

Rationale: The correct instruction for a client prescribed levothyroxine is to take the medication at the same time every day. This consistency is important for maintaining stable thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach to ensure proper absorption. Choice C is important but not directly related to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

4. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Hypotension
• C. Dry mucous membranes
• D. Tachypnea

Correct answer: C

Rationale: Correct! Dry mucous membranes are a common finding in clients with dehydration. Dehydration leads to reduced fluid volume in the body, resulting in dryness of mucous membranes, decreased skin turgor, and thirst. Bradycardia (slow heart rate) is not typically associated with dehydration, as the body tries to compensate for decreased fluid volume by increasing heart rate. Hypotension (low blood pressure) is a possible finding in dehydration due to reduced circulating volume. Tachypnea (rapid breathing) is more commonly seen in conditions like respiratory distress or metabolic acidosis, rather than dehydration.

5. A client who has a positive stool culture for Clostridium difficile should be placed in which type of room for infection control purposes?

• A. Wear a face shield prior to entering the room.
• B. Place the client in a private room.
• C. Place the client in a negative pressure room.
• D. Use an alcohol-based hand rub following client care.

Correct answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

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