Nursing Elites

1. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?

• A. Administer prescribed anticoagulant.
• B. Notify the healthcare provider.
• C. Auscultate lung sounds.
• D. Prepare for chest physiotherapy.

Correct answer: A

Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.

2. In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate closest proximal pulse.
• B. Note amount and color of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess skin elasticity of the stump.

Correct answer: A

Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.

3. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

• A. Localized warmth
• B. Calf pain
• C. Swelling in the affected leg
• D. Hematuria

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

4. The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?

• A. 100 ml/hour
• B. 75 ml/hour
• C. 60 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct infusion rate, convert 300 mcg/hour to mg/hour (300 mcg = 0.3 mg). Since the IV solution is 1 mg in 250 ml, the rate is calculated as 0.3 mg/hour = 75 ml/hour. Therefore, the nurse should set the pump to 75 ml/hour. Choice A (100 ml/hour) is incorrect as it does not reflect the accurate calculation. Choice C (60 ml/hour) is incorrect as it is lower than the correct rate. Choice D (125 ml/hour) is incorrect as it is higher than the correct rate.

5. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

• A. Instruct the client to use a moisturizer immediately after the bath
• B. Advise the client to take shorter baths with less water
• C. Suggest taking antihistamines for the pruritus
• D. Encourage the client to use cooler water and apply calamine lotion after soaking

Correct answer: D

Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.

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