Nursing Elites

1. Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

• A. Administer IV antibiotics through the implantable port.
• B. Monitor the IV sites for redness, swelling, or tenderness.
• C. Remove the patient’s nontunneled subclavian central venous catheter.
• D. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

Correct answer: B

Rationale: An experienced LPN/LVN can monitor IV sites for signs of infection because it falls within their education, experience, and scope of practice. Administering IV antibiotics through an implantable port, adjusting infusion rates, and removing central catheters are tasks that require RN level education and scope of practice. These activities involve a higher level of assessment, critical thinking, and potential complications that are typically within the RN's domain.

2. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• A. Blood pressure is 90/40 mm Hg.
• B. Urine output is 30 mL over the last hour.
• C. Oral fluid intake is 100 mL over the last 8 hours.
• D. There is prolonged skin tenting over the sternum.

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

3. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

• A. Discontinue the nasogastric suction.
• B. Give the patient the PRN IV morphine sulfate 4 mg.
• C. Notify the health care provider about the ABG results.
• D. Teach the patient how to take slow, deep breaths when anxious.

Correct answer: B

Rationale: The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

4. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

• A. Skin turgor
• B. Heart sounds
• C. Mental status
• D. Capillary refill

Correct answer: C

Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

5. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Tie the knot with a double turn or square knot
• B. Ensure that the restraints are snug against the client's wrists
• C. Ensure that the knot can be quickly released
• D. Move the ties so the restraints are secured to the side rails

Correct answer: C

Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.

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