Nursing Elites

1. A client is scheduled for a colonoscopy and has been prescribed a bowel preparation. What is the most important instruction for the nurse to provide?

• A. Eat a low-fiber diet the day before the procedure
• B. Drink clear liquids 24 hours before the procedure
• C. Take the entire bowel preparation as directed
• D. Avoid all solid foods 12 hours before the procedure

Correct answer: C

Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.

2. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

3. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

4. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?

• A. Check the client's most recent electrolyte levels.
• B. Administer a PRN dose of muscle relaxant.
• C. Reduce the weight on the traction device.
• D. Encourage oral fluid intake to relieve muscle tension.

Correct answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

5. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

• A. Monitor for signs of a pulmonary embolism.
• B. Assess for signs of dehydration.
• C. Monitor for signs of compartment syndrome.
• D. Check the client’s oxygen saturation levels.

Correct answer: A

Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.

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