Nursing Elites

1. How should a healthcare professional monitor for infection in a patient with a central line?

• A. Check the central line dressing daily
• B. Monitor for signs of redness
• C. Check for abnormal breath sounds
• D. Monitor temperature

Correct answer: A

Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.

2. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

• A. Administer sublingual nitroglycerin every 5 minutes
• B. Administer aspirin 325 mg
• C. Encourage the client to use deep breathing exercises
• D. Apply oxygen at 2 L/min via nasal cannula

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.

3. During an emergency response following a disaster, which client should be recommended for early discharge?

• A. A client with COPD and a respiratory rate of 44/min.
• B. A client with cancer and a sealed implant for radiation therapy.
• C. A client receiving heparin for deep-vein thrombosis.
• D. A client who is 1 day postoperative following a vertebroplasty.

Correct answer: D

Rationale: The client who is 1 day postoperative following a vertebroplasty is stable and can be discharged early. In an emergency response situation, it is crucial to prioritize clients who are medically stable and do not require immediate hospital care. The client with COPD and a respiratory rate of 44/min needs close monitoring and intervention. The client with cancer and a sealed implant for radiation therapy requires specialized care and follow-up. The client receiving heparin for deep-vein thrombosis needs ongoing anticoagulant therapy and monitoring, making early discharge not appropriate.

4. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 25 mg/dL
• B. Serum creatinine 1.5 mg/dL
• C. Serum glucose 110 mg/dL
• D. White blood cell (WBC) count 5,000/mm3

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

5. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume.
• B. Flush the tube with 0.9% sodium chloride.
• C. Elevate the head of the bed to 45 degrees.
• D. Warm the formula to body temperature.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees is the priority action before administering an enteral feeding through an NG tube. This position helps prevent aspiration by promoting proper flow and digestion of the feeding. Checking the residual volume, flushing the tube, and warming the formula are important steps but come after ensuring the client is in the correct position to minimize the risk of complications.

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