Nursing Elites

1. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

2. A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?

• A. Basic
• B. Commitment
• C. Complex
• D. Integrity

Correct answer: C

Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.

3. A healthcare professional is planning to perform ear irrigation on an adult client with impacted cerumen. Which of the following should the professional plan to take?

• A. Wearing sterile gloves while performing irrigation
• B. Positioning the client with the affected side down following irrigation
• C. Using cool fluid to irrigate the ear canal
• D. Pulling the pinna downward during irrigation

Correct answer: B

Rationale: Positioning the client with the affected side down following irrigation is crucial as it helps facilitate drainage of the dislodged cerumen and any remaining irrigation solution. This position allows gravity to assist in the removal of the loosened debris. Wearing sterile gloves is a standard precaution in healthcare procedures to prevent infection but is not specific to ear irrigation. Using body-temperature water or a solution at a slightly warmer temperature is recommended to prevent vertigo and discomfort, so using cool fluid is incorrect. Pulling the pinna upward and backward, not downward, straightens the ear canal for adults to facilitate the irrigation process, making choice D incorrect.

4. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

• A. Bleeding time
• B. Coagulation time
• C. Prothrombin time
• D. Partial thromboplastin time

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.

5. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?

• A. Ambulate the client 4 hours after the procedure
• B. Maintain the client on NPO status for 24 hours
• C. Monitor vital signs
• D. Change the dressing every 8 hours

Correct answer: C

Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.

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