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. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?

• A. Flushed skin
• B. Bradycardia
• C. Mental confusion
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Mental confusion. In this scenario, the client's high fever and pneumonia diagnosis indicate an infection. Infections, especially in older adults, can lead to mental confusion due to the body's systemic response to the infection. Flushed skin (choice A) is more commonly associated with fever but does not specifically relate to the client's condition. Bradycardia (choice B) and hypotension (choice D) are less likely findings in a client with pneumonia and a high fever; instead, tachycardia and increased blood pressure are more commonly seen in response to infection.

3. The milk code aims to ensure that:

• A. the public receives accurate information about breastmilk and breastfeeding
• B. health workers do not provide samples of infant formula to pregnant women or mothers of infants
• C. companies consistently recognize the superiority of breastmilk
• D. health workers do not accept any incentives from milk companies

Correct answer: C

Rationale: The correct answer is C because the milk code emphasizes that companies should always acknowledge the superiority of breastmilk over formula. Choice A is incorrect because the focus is not on the public receiving information, but rather on companies recognizing breastmilk's superiority. Choice B is incorrect as it addresses health workers' actions, not the companies' behavior. Choice D is incorrect as the milk code is primarily concerned with regulating companies' practices, not health workers' acceptance of incentives.

4. This refers to trained community health workers or health auxiliary volunteers:

• A. Village health workers
• B. Barangay health workers
• C. All of the above
• D. None of the above

Correct answer: C

Rationale: The correct answer is C, 'All of the above.' Both village health workers and barangay health workers are trained community health workers or health auxiliary volunteers. Choice A, 'Village health workers,' is correct as they are trained community health workers. Choice B, 'Barangay health workers,' is also correct as they also refer to trained community health workers. Therefore, since both options A and B are accurate, the correct answer is C, 'All of the above.' Choice D, 'None of the above,' is incorrect as both village health workers and barangay health workers fit the description provided in the question.

5. The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?

• A. Order a chest X-ray
• B. Obtain a peripheral O2 saturation reading
• C. Obtain an order for complete blood count
• D. Tell the patient to stay in bed

Correct answer: B

Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.

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