Nursing Elites

1. What is a crucial nursing responsibility when caring for a patient with a central line?

• A. Flush the line with saline
• B. Monitor for infection
• C. Monitor fluid balance
• D. Replace the central line

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is a crucial nursing responsibility. This is essential to prevent complications such as bloodstream infections. While flushing the line with saline and monitoring fluid balance are important aspects of care, they are not as critical as monitoring for infection. Replacing the central line is only done when necessary due to complications or at the end of its recommended use.

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

• A. Take this medication at bedtime.
• B. Avoid drinking alcohol while taking this medication.
• C. Eat 3 large meals each day.
• D. Report any muscle pain to your provider.

Correct answer: B

Rationale: The correct instruction the nurse should include for a client prescribed metformin is to avoid drinking alcohol. Alcohol consumption while on metformin increases the risk of lactic acidosis, a serious condition. Taking metformin at bedtime (choice A) is not a standard instruction. Eating 3 large meals each day (choice C) is not specific to metformin use and may not be suitable for all individuals. Reporting muscle pain (choice D) is important but not directly related to metformin use.

3. A client who had a colon resection and a new ascending colostomy is receiving discharge teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. My stool will become fully formed within 3 weeks.
• B. My skin should be cleaned with alcohol before applying a new pouch.
• C. I should avoid eating popcorn and fresh pineapple.
• D. I should expect bruising around the stoma.

Correct answer: C

Rationale: The correct answer is C because avoiding popcorn and fresh pineapple helps prevent complications with an ascending colostomy. Statements A, B, and D are incorrect. Statement A is inaccurate as it takes time for bowel function to normalize after surgery. Statement B is incorrect as alcohol can be irritating to the skin; gentle soap and water are recommended for cleaning. Statement D is incorrect as bruising around the stoma is not an expected outcome of colostomy creation.

4. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

5. A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1,500 mL per day.
• B. Encourage the client to walk every 2 hours.
• C. Monitor the client's weight daily.
• D. Administer oxygen via nasal cannula at 2 L/min.

Correct answer: C

Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.

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