Nursing Elites

1. The nurse is assessing a client with an IV infusion of normal saline. The client reports pain and swelling at the IV site. What should the nurse do first?

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

Correct answer: D

Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.

2. Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)

• A. Heart rate
• B. Stroke volume
• C. Peripheral resistance
• D. Neuroendocrine hormones

Correct answer: D

Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.

3. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?

• A. Use short, simple sentences and maintain a calm demeanor
• B. Involve family members to provide reassurance
• C. Offer choices to empower the client
• D. All of the above

Correct answer: D

Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.

4. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

• A. Administer insulin as prescribed
• B. Provide a carbohydrate-controlled snack
• C. Encourage physical activity
• D. Recheck the blood sugar

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?

• A. Administer a high-flow oxygen mask.
• B. Position the client in a high-Fowler's position.
• C. Provide a high-carbohydrate diet.
• D. Encourage the client to cough and deep breathe.

Correct answer: B

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.

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