Nursing Elites

1. What is the most important action for preventing infection in a client with a central venous catheter?

• A. Changing the catheter dressing every 72 hours.
• B. Flushing the catheter with heparin solution daily.
• C. Ensuring the catheter is clamped when not in use.
• D. Maintaining sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.

2. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Delete the space between the numerical dose and the unit of measure.
• C. Write the letter U when noting the dosage of insulin.
• D. Use the abbreviation SC when indicating an injection.

Correct answer: A

Rationale: The correct answer is to use the complete name of the medication magnesium sulfate. This is important to prevent confusion with morphine sulfate, which is abbreviated as MSO4. Choice B is incorrect as it is essential to maintain a space between the numerical dose and the unit of measure for clarity in medication documentation. Choice C is incorrect as the standard abbreviation for units is 'U' for international units, not for the dosage of insulin. Choice D is incorrect as the appropriate abbreviation for subcutaneous injection is 'SC,' not just 'SC.' Therefore, the nurse manager should emphasize using the full name of medications to avoid errors and ensure patient safety.

3. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

4. When assessing the skin of an immobilized patient, what should the nurse do?

• A. Assess the skin every 4 hours.
• B. Limit the amount of fluid intake.
• C. Use a standardized tool such as the Braden Scale.
• D. Have special times for inspection to not interrupt routine care.

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

5. A client is lying on the bathroom floor after a nurse responds to a call light. Which of the following actions should the nurse take first?

• A. Check the client for injuries
• B. Move hazardous objects away from the client
• C. Notify the provider
• D. Ask the client to describe how she felt prior to the fall

Correct answer: A

Rationale: The nurse's priority in this situation is to assess the client for injuries. Checking for injuries first is crucial to determine the extent of harm caused by the fall and to provide immediate care. Moving hazardous objects can wait until the client's safety is ensured. Notifying the provider and asking the client about how she felt prior to the fall are important but are secondary to assessing for injuries in this urgent scenario. It is essential to address immediate physical needs before investigating the cause of the fall or notifying other healthcare team members.

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