Nursing Elites

1. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

2. What are the common side effects of opioid analgesics, and how should they be managed?

• A. Drowsiness and dizziness, ensuring safety precautions
• B. Respiratory depression, ensuring adequate ventilation
• C. Constipation and nausea, managed with stool softeners
• D. Nausea and vomiting, managing with antiemetics

Correct answer: A

Rationale: The correct answer is A. Common side effects of opioid analgesics include drowsiness and dizziness. These side effects can impair a person's ability to operate machinery or drive safely. To manage these side effects, it is essential to advise patients to avoid activities that require alertness until they know how the medication affects them. Choices B, C, and D are incorrect because respiratory depression, constipation, and nausea are also common side effects of opioids, but they are not the primary side effects being asked for in this question.

3. A nurse is preparing a client for surgery. Which of the following actions should be taken first?

• A. Ensure informed consent is signed
• B. Start IV fluids
• C. Administer preoperative antibiotics
• D. Reinforce surgical site dressing

Correct answer: A

Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.

4. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

• A. I wish I didn't have to attach the electrodes to my skin
• B. I will need to shave the hair off the skin where I place the electrodes
• C. I hope I don't have to take as many pain pills
• D. It's unfortunate that I have to be in the hospital for this treatment

Correct answer: D

Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.

5. A client requires suctioning every 2 hours. To whom should the nurse delegate this task?

• A. Delegate to a licensed practical nurse (LPN)
• B. Delegate to a registered nurse (RN)
• C. Delegate to a nursing assistant (NA)
• D. Perform the task independently

Correct answer: A

Rationale: The correct answer is to delegate the task to a licensed practical nurse (LPN). LPNs can typically perform suctioning, but it is essential to consider the state's practice guidelines and hospital policy. Option B, delegating to a registered nurse (RN), is not necessary for this task as LPNs are usually competent to handle suctioning. Option C, delegating to a nursing assistant (NA), may not be appropriate as suctioning may require a higher level of training and expertise. Option D, performing the task independently, is not the best choice as delegation is a key aspect of nursing practice to ensure tasks are appropriately assigned based on competency levels.

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