Nursing Elites

1. During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?

• A. Discontinue the IV under physician's guidance
• B. Apply a warm compress to the site
• C. Notify the physician
• D. Document the appearance of the site and continue the bath

Correct answer: C

Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.

2. After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?

• A. Instruct the client to take deep breaths.
• B. Place a wedge under the client's hip.
• C. Place the client in the Trendelenburg position.
• D. Remove the client's legs from the stirrups.

Correct answer: B

Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (Choice A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (Choice C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (Choice D) may provide temporary relief but does not address the root cause of the issue.

3. A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?

• A. Offer information about the procedure steps
• B. Administer an anxiolytic before the procedure
• C. Encourage the client to discuss their fears
• D. Reassure the client that the procedure is common and safe

Correct answer: C

Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.

4. When teaching a client about managing hypertension, what dietary advice should be emphasized?

• A. Reduce sodium intake
• B. Increase potassium intake
• C. Limit alcohol consumption
• D. All of the above

Correct answer: D

Rationale: When managing hypertension, it is crucial to adopt comprehensive dietary changes. This includes reducing sodium intake to help lower blood pressure, increasing potassium intake to counteract the effects of sodium and help regulate blood pressure, and limiting alcohol consumption as excessive alcohol can raise blood pressure. Therefore, emphasizing all the options provided (A, B, and C) is essential in effectively managing hypertension and reducing overall cardiovascular risk. Choices A, B, and C are not individually sufficient as a single dietary modification but collectively work together to support blood pressure management.

5. The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?

• A. Slow the rate of infusion
• B. Apply a warm compress to the site
• C. Discontinue the IV infusion
• D. Elevate the affected arm

Correct answer: C

Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.

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