Nursing Elites

1. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour
• D. Drink approximately 4 ounces of water every hour

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

2. Which of the following is a symptom associated with sensory overload?

• A. Disorientation
• B. Drowsiness
• C. Emotional lability
• D. Depression

Correct answer: A

Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.

3. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

• A. The client will experience increased tolerance to the drug's effects and may need a higher dose.
• B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
• C. The medication will be more highly protein-bound, increasing the duration of action.
• D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

Correct answer: B

Rationale: When changing the route of administration from PO to IV, the absorption process is bypassed, leading to a more rapid onset of action of the medication and consequently a quicker effect. Choices A, C, and D are incorrect. Increased drug tolerance and higher doses are not typical outcomes of changing the route of administration. Protein binding does not increase with a change to IV administration; rather, it is the bioavailability and onset of action that are affected. Moreover, an increased therapeutic index reduces the risk of drug toxicity, contrary to what is stated in choice D.

4. The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.

5. What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?

• A. Encouraging the father to participate in a parenting class
• B. Providing time for the father to be alone with and get to know the baby
• C. Offering the father a demonstration on newborn diapering, feeding, and bathing
• D. Allowing time for the father to ask questions after viewing a film about a new baby

Correct answer: B

Rationale: The priority nursing action to assist an anxious father in his concern about not bonding with his newborn is providing time for the father to be alone with and get to know the baby. Time alone provides the opportunity for paternal-infant attachment and bonding, which can help reduce the father's anxiety. Encouraging the father to participate in a parenting class, although helpful, does not directly address the immediate need for bonding. Offering a demonstration on newborn care tasks like diapering, feeding, and bathing may not effectively address the father's anxiety at that moment, as he may not be ready to absorb such information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach that may not adequately address the emotional needs and concerns of the father regarding bonding with his newborn.

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