Nursing Elites

1. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

• A. The IV fluids are infusing into the subcutaneous tissues
• B. The infusion pump is functioning properly
• C. The insertion date should be verified and the IV discontinued
• D. The site is inflamed and should be reported

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

2. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?

• A. Use sterile technique for catheter care
• B. Ensure the catheter bag is below the level of the bladder
• C. Provide perineal care daily
• D. Change the catheter only when necessary

Correct answer: B

Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.

3. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?

• A. Check for catheter patency
• B. Assess the color of the urine
• C. Measure the urine output
• D. Ensure the catheter tubing is secure

Correct answer: C

Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.

4. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

5. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

• A. Advise the client that suctioning will be used to obtain another specimen
• B. Re-instruct the client in coughing techniques to obtain another specimen
• C. Provide the client a glass of water and mouthwash to rinse the mouth
• D. Label the container and place the container in a biohazard transport bag

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

Similar Questions