Nursing Elites

1. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?

• A. You seem worried. Are you concerned someone may see you without your teeth?
• B. Don't worry, it’s just for the surgery.
• C. You need to follow the instructions.
• D. The dentures need to be removed for a reason.

Correct answer: D

Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.

3. A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?

• A. Obtain a thermometer with a short, blunt insertion end
• B. Use the available thermometer as is
• C. Request a new thermometer
• D. Measure the temperature orally instead

Correct answer: A

Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.

4. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

5. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

• A. Erythema along the path of the vein
• B. Pitting edema at the insertion site
• C. Coolness of the client’s left forearm
• D. Pallor of the client’s left forearm

Correct answer: A

Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.

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