Nursing Elites

1. The healthcare professional is caring for a client with a peripheral intravenous (IV) line that has infiltrated. What is the most appropriate initial action for the healthcare professional to take?

• A. Apply a warm compress to the affected area.
• B. Discontinue the IV and restart it in another site.
• C. Aspirate the IV line and flush it with normal saline.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: The correct initial action when an IV line infiltrates is to discontinue the IV and restart it in another site. This is crucial to prevent complications such as tissue damage, phlebitis, and infection that can result from the infiltration. Applying a warm compress (Choice A) is not recommended as it can exacerbate the tissue damage caused by the infiltration. Aspirating the IV line and flushing it with normal saline (Choice C) is not appropriate for an infiltrated IV line as it does not address the main issue of infiltration. While notifying the healthcare provider (Choice D) is important, the immediate priority is to discontinue the infiltrated IV to prevent further harm and ensure proper delivery of fluids or medications.

2. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?

• A. Hypertension
• B. Bradycardia
• C. Hypoglycemia
• D. Weight gain

Correct answer: A

Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.

3. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first?

• A. Sexual activity patterns.
• B. Nutritional history.
• C. Leisure activities.
• D. Financial stressors.

Correct answer: B

Rationale: The LPN/LVN should first obtain the nutritional history in this scenario. Nutrition plays a crucial role in mental health, and deficiencies or imbalances in diet can contribute to anxiety symptoms. Understanding the mother's nutritional intake can help identify any factors exacerbating her anxiety. Sexual activity patterns are not directly relevant to her anxiety symptoms unless specifically indicated. Leisure activities and financial stressors may be important but are secondary to addressing the potential impact of nutrition on anxiety.

4. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

5. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

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