Nursing Elites

1. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?

• A. The solution's rate is too rapid
• B. The client has phlebitis
• C. The infusion site is infected
• D. The infusion is infiltrated

Correct answer: D

Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.

2. The nurse is caring for a client who has just returned from surgery with a urinary catheter in place. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs)?

• A. Irrigate the catheter daily
• B. Ensure the catheter bag is always below bladder level
• C. Change the catheter every 48 hours
• D. Administer prophylactic antibiotics

Correct answer: B

Rationale: The correct answer is to ensure the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Choice A, irrigating the catheter daily, is not recommended as it can introduce pathogens into the bladder. Changing the catheter too frequently (Choice C) can increase the risk of introducing pathogens. Administering prophylactic antibiotics (Choice D) is not the primary intervention for preventing CAUTIs and can lead to antibiotic resistance.

3. The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. What response should the nurse provide first?

• A. The letters represent tumor size, node involvement, and metastasis in cancer staging.
• B. The letters stand for tumor size, node involvement, and metastasis.
• C. Let me explain the cancer staging to you.
• D. Would you like further clarification on the tumor staging?

Correct answer: B

Rationale: Choice B is the correct answer as it accurately explains that the letters T, N, and M in cancer staging represent tumor size, node involvement, and metastasis, respectively. Understanding this staging system helps the client comprehend the extent and severity of the disease. Choices A, C, and D are incorrect. Choice A has the correct information but is not the most precise response. Choice C is vague and does not directly address the client's need for clarification. Choice D offers further clarification without directly addressing the initial explanation provided by the healthcare provider.

4. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?

• A. Avoid driving for at least 2 weeks
• B. Resume a low-fat diet
• C. Remove the bandages from the incision after 24 hours
• D. Expect significant pain for the first week

Correct answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

5. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

• A. Keeping the head of the bed elevated at 30 degrees
• B. Positioning the client in the prone position
• C. Placing the client in a lateral recumbent position
• D. Elevating the client's legs

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

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