Nursing Elites

1. What is the best way to monitor for infection in a patient with a central line?

• A. Check the central line site daily
• B. Monitor the patient's vital signs
• C. Check the central line dressing every other day
• D. Check for signs of sepsis

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

2. A nurse is caring for a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. You should avoid eating foods high in potassium.
• C. You should take this medication with meals to improve absorption.
• D. Take this medication before bed to prevent drowsiness.

Correct answer: C

Rationale: The correct instruction for a client prescribed metformin is to take the medication with meals to improve absorption and reduce gastrointestinal upset. Metformin is typically recommended to be taken with food to minimize side effects. Option A is incorrect as taking metformin on an empty stomach may increase the risk of gastrointestinal side effects. Option B is unrelated as metformin does not interact with potassium-rich foods. Option D is also incorrect as metformin does not cause drowsiness, so there is no need to take it before bed.

3. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

4. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns
• B. Support the family's decision and initiate life-sustaining measures
• C. Complete an incident report
• D. Encourage the family to contact an attorney

Correct answer: A

Rationale: In this scenario, the nurse should arrange for an ethics committee meeting to address the family's concerns while ensuring the client's wishes are respected. Choosing option A allows for a formal discussion involving healthcare professionals, family members, and possibly a legal expert to navigate the situation ethically and legally. Supporting the family's decision to initiate life-sustaining measures (option B) would disregard the client's advance directives and autonomy. Completing an incident report (option C) is not appropriate in this situation as it does not address the conflict of interest between the family's desires and the client's wishes. Encouraging the family to contact an attorney (option D) may escalate the situation unnecessarily before exploring more ethical and collaborative approaches.

5. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

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