Nursing Elites

1. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

2. When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?

• A. At the time of admission
• B. The day before the patient is to be discharged
• C. When outpatient therapy is no longer needed
• D. As soon as the patient's discharge destination is known

Correct answer: A

Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.

3. When taking a history of a 3-year-old with neuroblastoma, what comment by the parents requires follow-up and is consistent with the diagnosis?

• A. The child has been listless and has lost weight.
• B. The urine is dark yellow and in small amounts.
• C. Clothes are becoming tighter across her abdomen.
• D. We notice muscle weakness and some unsteadiness.

Correct answer: C

Rationale: The correct answer is C. Clothes becoming tighter across the abdomen is indicative of an abdominal mass, a common presentation in neuroblastoma. This symptom should be followed up on further as it aligns with the diagnosis. Choices A, B, and D are less specific to neuroblastoma. Weight loss and listlessness (Choice A) can be nonspecific symptoms, while dark yellow urine in small amounts (Choice B) may suggest dehydration or other conditions. Muscle weakness and unsteadiness (Choice D) could point towards various neurological or muscular issues but are not as directly related to neuroblastoma as the symptom described in Choice C.

4. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?

• A. Call the Poison Control Center as soon as the situation is identified
• B. Empty the child's mouth in any case of possible poisoning
• C. Have the child move minimally if a toxic substance was inhaled
• D. Do not induce vomiting if the poison is a hydrocarbon

Correct answer: B

Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.

5. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

• A. Remove elastic stockings every 4 hours.
• B. Measure the calf circumference of both legs.
• C. Lightly rub the lower leg for redness and tenderness.
• D. Dorsiflex the foot while assessing for patient discomfort.

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

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