Nursing Elites

1. A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?

• A. The ulcer has a pale-colored base.
• B. The ulcer is deep, with even edges.
• C. The ulcer has little granulation tissue.
• D. The ulcer has a brownish or 'brawny' appearance.

Correct answer: D

Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. The correct answer is not A because venous stasis ulcers typically do not have a pale-colored base. Choice B is incorrect as venous stasis ulcers usually have irregular, shallow edges, not deep and even edges. Choice C is incorrect as venous stasis ulcers often have excess granulation tissue, not little granulation tissue. Recognizing the brownish or 'brawny' appearance is crucial for accurate diagnosis and appropriate treatment of venous stasis leg ulcers.

2. A client has a new prescription for lisinopril. Which of the following instructions should the nurse include?

• A. Monitor blood pressure daily.
• B. Take the medication with food.
• C. Increase intake of potassium-rich foods.
• D. Avoid consuming grapefruit juice.

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor their blood pressure daily. Lisinopril is known to cause hypotension, so monitoring blood pressure regularly is essential to detect any potential issues early on. Choice B is incorrect as lisinopril is usually taken on an empty stomach. Choice C is incorrect as lisinopril can increase potassium levels, so additional intake of potassium-rich foods may lead to hyperkalemia. Choice D is incorrect because grapefruit juice can interact with lisinopril, leading to adverse effects.

3. The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?

• A. Avoid consuming foods high in vitamin K while taking this medication.
• B. Administer the injection in the same site each time for consistency.
• C. Report any unusual bleeding or bruising to your healthcare provider.
• D. Do not take aspirin if you experience any mild pain or discomfort.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is crucial because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin. Prompt reporting to a healthcare provider is necessary to prevent complications. Choices A, B, and D are incorrect. Choice A is not directly related to enoxaparin and vitamin K interactions. Choice B is incorrect as rotating injection sites is essential for preventing tissue damage and irritation. Choice D is also incorrect as aspirin can increase the risk of bleeding when taken with enoxaparin.

4. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?

• A. Obtain a prescription for pain medication.
• B. Have the client stop and lie back down in bed.
• C. Report the complaint to the healthcare provider.
• D. Instruct the client to continue getting out of bed and into a chair.

Correct answer: B

Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain. Option A is incorrect as pain medication should not be the initial action for chest pain in CAD. Option C is incorrect because the nurse should first intervene directly to address the chest pain. Option D is incorrect as continuing the activity can worsen the myocardial ischemia and chest pain.

5. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

• A. Shave the front of the client's chest
• B. Give the client a device holder to wear around the waist
• C. Teach the client to rest as much as possible during the next 24 hours
• D. Tell the client to cover the monitor in plastic wrap before taking a bath

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

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