Nursing Elites

1. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

• A. Elevate leg on 2 pillows
• B. Apply support stockings
• C. Apply warm compresses
• D. Maintain complete bed rest

Correct answer: A

Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.

2. Which bioterrorism agent poses a high risk for use as a potential biological weapon due to its ability to be readily transmitted through several portals of entry?

• A. Anthrax.
• B. Smallpox.
• C. Botulism.
• D. Tularemia.

Correct answer: A

Rationale: The correct answer is Anthrax. Anthrax is a high-risk bioterrorism agent because it can be readily transmitted through multiple portals of entry such as inhalation, ingestion, or skin contact. This makes it a significant concern for use as a biological weapon. Smallpox, though highly contagious, is not known for multiple portals of entry like Anthrax. Botulism is a potent toxin but is not as easily transmissible through various routes as Anthrax. Tularemia, while a serious bacterial infection, does not have the same ease of transmission through multiple portals of entry as Anthrax.

3. The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate?

• A. An excess of red blood cells
• B. An excess of white blood cells
• C. A deficiency of clotting factor VIII
• D. A deficiency of clotting factors VIII and IX

Correct answer: C

Rationale: The correct answer is C: A deficiency of clotting factor VIII. Hemophilia A is characterized by a lack of clotting factor VIII, which is crucial for blood clotting. This deficiency results in prolonged bleeding. Choices A, B, and D are incorrect. There is no association between Hemophilia A and an excess of red blood cells (Choice A) or an excess of white blood cells (Choice B). Additionally, Hemophilia A specifically involves a deficiency of clotting factor VIII, not both factors VIII and IX (Choice D).

4. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

• A. Ensure that adequate mist is supplied
• B. Inspect the nares and ears for skin breakdown
• C. Lubricate the tips of the cannula before insertion
• D. Maintain sterile technique when handling the cannula

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

5. The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

• A. Reduce the environmental stimuli
• B. Offer formula every 2 hours
• C. Talk to the newborn while feeding
• D. Rock the baby frequently

Correct answer: A

Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.

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