Nursing Elites

1. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?

• A. Apply a tourniquet above the insertion site
• B. Shave the area around the insertion site
• C. Insert the catheter at a 15-degree angle
• D. Use an 18-gauge needle for insertion

Correct answer: C

Rationale: The correct answer is to insert the catheter at a 15-degree angle. This angle allows for easier venous access by ensuring proper catheter placement into the vein. Applying a tourniquet above the insertion site can help distend the vein for better visualization but is not the immediate action required for the insertion process. Shaving the area around the insertion site is not necessary unless there is excessive hair that may interfere with the insertion. Using an 18-gauge needle for insertion is a specific detail related to the equipment rather than the technique of insertion.

2. How should a healthcare provider monitor a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT (activated partial thromboplastin time) when a patient is receiving heparin therapy. aPTT monitoring is essential for assessing the therapeutic effectiveness of heparin, ensuring the patient is within the desired therapeutic range to prevent both clotting and bleeding. Monitoring platelet count (Choice B) is important for assessing for heparin-induced thrombocytopenia but is not the primary monitoring parameter for heparin therapy. Monitoring sodium levels (Choice C) and calcium levels (Choice D) are not directly related to assessing the therapeutic effectiveness or potential side effects of heparin therapy.

3. What is the appropriate action when a patient experiences an allergic reaction to a medication?

• A. Administer epinephrine
• B. Discontinue the medication
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.

4. A client with a new diagnosis of Crohn's disease is receiving teaching from a nurse. Which statement by the client demonstrates an understanding of the teaching?

• A. I should eat more fiber to help with my bowel movements.
• B. I will need to have routine colonoscopies to monitor my condition.
• C. I will limit my intake of whole grains.
• D. I should consume a low-fat diet.

Correct answer: B

Rationale: The correct answer is B. Clients with Crohn's disease require routine colonoscopies to monitor disease progression and complications. This helps healthcare providers assess the status of the disease and make informed treatment decisions. Choice A is incorrect because while fiber may be beneficial for some digestive conditions, it can exacerbate symptoms in Crohn's disease. Choice C is incorrect as whole grains can be a good source of nutrients unless they individually trigger symptoms in the client. Choice D is also incorrect since a low-fat diet is not a specific requirement for managing Crohn's disease.

5. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

• A. A chest x-ray reveals increased density in all fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated bilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

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