Nursing Elites

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

• A. Choose the most distal site on the selected extremity
• B. Apply a cool compress to the selected extremity before insertion of the IV catheter
• C. Stroke the selected extremity before insertion of the IV catheter
• D. Place the tourniquet above the proposed insertion site

Correct answer: C

Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.

2. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

• A. Role overload
• B. Role conflict
• C. Role ambiguity
• D. Role strain

Correct answer: A

Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.

3. A nurse in a provider’s office is caring for a client who states, “I always have trouble sleeping.” Which of the following actions should the nurse take first?

• A. Teach the client stress reduction techniques
• B. Recommend that the client avoid caffeine intake in the evening
• C. Identify the client’s typical bedtime routine
• D. Encourage the client to exercise regularly during daytime hours

Correct answer: C

Rationale: The correct action for the nurse to take first is to identify the client’s typical bedtime routine. Understanding the client’s sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.

4. The client with gastroesophageal reflux disease (GERD) is receiving dietary modification education from the nurse. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating large meals before bedtime.
• B. I will limit coffee consumption to the morning hours.
• C. I will elevate the head of my bed while sleeping.
• D. I will avoid spicy and acidic foods.

Correct answer: B

Rationale: The correct answer is B. Clients with GERD should avoid coffee as it can relax the lower esophageal sphincter and exacerbate symptoms. Limiting coffee consumption to the morning hours may not be sufficient, as coffee can still contribute to GERD symptoms throughout the day. Choices A, C, and D are all appropriate strategies for managing GERD symptoms. Avoiding large meals before bedtime, elevating the head of the bed while sleeping, and steering clear of spicy and acidic foods are all recommended practices to help alleviate GERD symptoms. Therefore, the client's statement in option B indicates a need for further teaching to completely address dietary modifications for managing GERD.

5. A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?

• A. I'm glad I don’t have to lie still for this procedure.
• B. I will have a local anesthetic to help with discomfort.
• C. I hope I get some medicine to relax me.
• D. I can't eat or drink for 6 hours before the procedure.

Correct answer: A

Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.

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