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 client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

3. When evaluating care of an immobilized patient, which action will the nurse take?

• A. Focus on whether the interdisciplinary team is satisfied with the care.
• B. Compare the patient's actual outcomes with the outcomes in the care plan.
• C. Involve primarily the patient's family and health care team to determine goal achievement.
• D. Use objective data solely in determining whether interventions have been successful.

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

4. A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?

• A. Airborne
• B. Droplet
• C. Protective
• D. Contact

Correct answer: A

Rationale: Tuberculosis is an infectious disease that requires airborne precautions to prevent the transmission of infectious droplets. Airborne precautions involve wearing a mask, such as an N95 respirator, to protect against inhaling infectious particles. Droplet precautions are for diseases spread through respiratory droplets larger than those in airborne transmission, such as influenza. Protective precautions are not specific to respiratory infections and are more general measures to protect patients from harm. Contact precautions are used for diseases spread by direct or indirect contact, such as MRSA or C. diff infections, not for tuberculosis.

5. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

• A. Decreased subcutaneous fat
• B. Muscle atrophy
• C. Pressure injury
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

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