Nursing Elites

1. What is the most important nursing action when a patient has a central line?

• A. Monitor for infection
• B. Monitor the central line dressing
• C. Monitor for redness
• D. Monitor for swelling

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

2. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.

3. A nurse is caring for a client who is 32 weeks pregnant and has cardiac disease. Which of the following positions should the nurse place the client in to promote optimal cardiac output?

• A. Semi-Fowler's
• B. Supine with head elevated
• C. Left lateral
• D. Right lateral

Correct answer: C

Rationale: The correct answer is C: Left lateral. Placing the client in the left lateral position helps promote optimal cardiac output during pregnancy by avoiding pressure on the vena cava. This position improves venous return to the heart and subsequently cardiac output. Option A, Semi-Fowler's position, may not be the best choice for a client with cardiac disease as it does not alleviate pressure on the vena cava. Option B, supine with head elevated, can also compress the vena cava, reducing cardiac output. Option D, right lateral position, does not provide the same benefits as the left lateral position for cardiac output during pregnancy.

4. A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?

• A. Increase the dose of haloperidol.
• B. Administer benztropine.
• C. Administer naloxone.
• D. Monitor blood pressure before administering the next dose.

Correct answer: B

Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.

5. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

• A. INR 1.8
• B. Hemoglobin 14 g/dL
• C. Platelets 175,000/mm³
• D. Potassium 3.8 mEq/L

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

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