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. A nurse in a provider’s office is caring for a client who states, “I always have trouble sleeping.” Which of the following actions should the nurse take first?

• A. Teach the client stress reduction techniques
• B. Recommend that the client avoid caffeine intake in the evening
• C. Identify the client’s typical bedtime routine
• D. Encourage the client to exercise regularly during daytime hours

Correct answer: C

Rationale: The correct action for the nurse to take first is to identify the client’s typical bedtime routine. Understanding the client’s sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.

3. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?

• A. Consult the medication reference book available on the unit.
• B. Administer the medication as ordered.
• C. Ask a colleague for information about the medication.
• D. Contact the provider to clarify the medication.

Correct answer: A

Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.

4. The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?

• A. Providing nail care
• B. Teaching foot care
• C. Making the patient's bed
• D. Determining aspiration risk

Correct answer: C

Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.

5. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following techniques should the nurse identify as indicating the correct method for eliciting the client's patellar reflex?

• A. Tap just below the knee
• B. Tap on the upper thigh
• C. Tap on the ankle
• D. Tap on the lower leg

Correct answer: A

Rationale: The correct technique for eliciting the client's patellar reflex is to tap just below the knee. This action stimulates the stretch receptors in the patellar tendon, leading to a reflex contraction of the quadriceps muscle and extension of the lower leg. Tapping on the upper thigh (Choice B) would not elicit the patellar reflex as it targets a different area. Similarly, tapping on the ankle (Choice C) or tapping on the lower leg (Choice D) would not produce the desired response associated with the patellar reflex, making them incorrect choices.

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