Nursing Elites

1. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter dressing every 72 hours.
• B. Flush the catheter with heparin solution daily.
• C. Ensure the catheter is clamped when not in use.
• D. Maintain sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

2. A client is 48 hours postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

• A. Impaired peristalsis of the intestines
• B. Infection at the surgical site
• C. Fluid overload
• D. Inadequate pain management

Correct answer: A

Rationale: Gas pains in the periumbilical area postoperatively are often caused by impaired peristalsis and bowel function. Following abdominal surgery, it is common for peristalsis to be reduced due to surgical manipulation and anesthesia effects. This reduction in peristalsis can lead to the accumulation of gas in the intestines, resulting in gas pains. Infection at the surgical site (Choice B) would present with localized signs of infection such as redness, swelling, warmth, and drainage, rather than diffuse gas pains. Fluid overload (Choice C) would manifest with symptoms such as edema, increased blood pressure, and respiratory distress, not gas pains. Inadequate pain management (Choice D) may lead to increased discomfort, but it is not the primary cause of gas pains in the periumbilical area following a small bowel resection.

3. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

• A. Administer nitroglycerin sublingually.
• B. Obtain a 12-lead ECG.
• C. Measure the client's vital signs.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

4. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

5. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

• A. Check the IV tubing for obstruction
• B. Increase the infusion rate
• C. Administer a bolus of fluid
• D. Replace the IV catheter

Correct answer: A

Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.

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