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 reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

3. A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of sterile water before each feeding
• B. Administer the feeding using a large-bore syringe
• C. Keep the head of the bed elevated to 15 degrees
• D. Replace the feeding bag every 24 hours

Correct answer: A

Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.

4. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

5. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

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