Nursing Elites

1. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?

• A. I should avoid eating green leafy vegetables.
• B. I should wear loose-fitting clothes to avoid pressure on my legs.
• C. I should avoid prolonged sitting or standing.
• D. I should continue taking my over-the-counter herbal supplements.

Correct answer: D

Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.

2. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
• B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

3. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

• A. Removing the empty food tray from a client with a urinary catheter.
• B. Washing and combing the hair of a client with a fractured leg in traction.
• C. Administering oral medications to a cooperative client with a wound infection.
• D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

4. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

• A. Document the client's request in the medical record.
• B. Ask the client if this decision has been discussed with his healthcare provider.
• C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
• D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Correct answer: B

Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.

5. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

• A. The client reports pain at the IV site
• B. The client’s blood pressure is elevated
• C. The client has swelling at the IV site
• D. The client’s heart rate is irregular

Correct answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

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