Nursing Elites

1. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

• A. Pallor
• B. Increased temperature
• C. Dyspnea
• D. Involuntary muscle spasms

Correct answer: C

Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.

2. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

3. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?

• A. Check the protein level in urine
• B. Have the client turn to the left side
• C. Take the temperature
• D. Monitor the urine output

Correct answer: B

Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.

4. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

• A. Increased blood pressure
• B. Increased heart rate
• C. Loss of pulse in the extremity
• D. Decreased urine output

Correct answer: C

Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.

5. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?

• A. Administer insulin as ordered
• B. Encourage the client to drink fluids
• C. Notify the healthcare provider
• D. Recheck the blood glucose level in 30 minutes

Correct answer: A

Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.

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