Nursing Elites

1. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

• A. Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your surgeon and find out if Heparin IV therapy can be administered to you at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

2. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

3. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

• A. Perform passive range of motion to the right leg
• B. Remove skeletal weights every shift to assess right leg
• C. Turn frequently from prone to supine positions
• D. Maintain skeletal pin sites and assess for signs of infection

Correct answer: D

Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.

4. The client is being taught how to take alendronate (Fosamax) for osteoporosis treatment. Which statement indicates that the client needs further teaching?

• A. I should take this medication at bedtime
• B. I will need to take this medication for at least 3 years
• C. I should sit up for 30 minutes after taking the medication
• D. I should take this medication with a full glass of water

Correct answer: A

Rationale: The correct answer is A because taking Fosamax at bedtime is incorrect. It should be taken in the morning with a full glass of water to prevent esophageal irritation. Choice B is correct; alendronate is typically taken for several years to treat osteoporosis. Choice C is correct as remaining upright for 30 minutes after taking Fosamax helps prevent esophageal irritation. Choice D is also correct as taking alendronate with a full glass of water is necessary to ensure proper absorption.

5. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

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