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 received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow down the rate of the transfusion
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.

3. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?

• A. Encourage the client to ambulate
• B. Apply a heating pad
• C. Provide a carbonated beverage
• D. Teach relaxation techniques

Correct answer: A

Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.

4. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

5. A client with chronic kidney disease is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Decreased urine output
• B. Weight loss of 1 kg
• C. Blood pressure of 150/90 mm Hg
• D. Presence of a bruit over the fistula

Correct answer: C

Rationale: The correct answer is C. An elevated blood pressure in clients with chronic kidney disease undergoing hemodialysis can indicate fluid overload or poor dialysis efficacy and should be reported immediately. This finding could lead to complications such as heart failure or pulmonary edema. Choices A, B, and D are not as critical in this situation. Decreased urine output may be expected due to the kidney disease, a weight loss of 1 kg is within an acceptable range, and the presence of a bruit over the fistula is a common finding in clients undergoing hemodialysis and does not require immediate reporting.

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