Nursing Elites

1. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left lower extremity. Which of the following findings should the nurse expect?

• A. Pain in the right lower extremity
• B. Cold skin in the affected extremity
• C. Redness and warmth in the affected extremity
• D. Shiny skin on the affected extremity

Correct answer: C

Rationale: Corrected Rationale: Redness and warmth are classic signs of inflammation, which are commonly seen in clients with deep vein thrombosis (DVT). These findings indicate increased blood flow and temperature in the affected area. Pain in the right lower extremity (Choice A) is not expected in a client with DVT affecting the left lower extremity. Cold skin (Choice B) is not a typical finding in DVT; instead, warmth is more indicative of inflammation. Shiny skin (Choice D) is not a common characteristic of DVT; rather, the skin may appear red, swollen, and warm due to the inflammatory process.

2. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

3. A nurse is caring for a client who is receiving furosemide. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Serum sodium.
• B. Serum glucose.
• C. Serum potassium.
• D. Serum calcium.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Furosemide is a potassium-wasting diuretic, meaning it can lead to potassium loss in the body. Monitoring serum potassium levels is crucial to evaluate the effectiveness of furosemide and prevent hypokalemia. Options A, B, and D are incorrect because furosemide does not directly affect sodium, glucose, or calcium levels in the same way it impacts potassium levels.

4. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following actions should the nurse take?

• A. Encourage the client to increase physical activity.
• B. Place the client in the Trendelenburg position.
• C. Limit the client's fluid intake to prevent fluid overload.
• D. Administer high-flow oxygen via mask.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with COPD is to encourage the client to increase physical activity. Increased physical activity helps manage COPD symptoms by improving lung function and preventing deconditioning. Placing the client in the Trendelenburg position is not recommended for COPD as it can worsen breathing difficulties. Limiting fluid intake to prevent fluid overload is not typically necessary in COPD unless the client has comorbid conditions that require fluid restriction. Administering high-flow oxygen via mask may be necessary for COPD clients with severe hypoxemia, but it is not the initial action for planning care.

5. A client is experiencing a panic attack. Which of the following actions should the nurse take first?

• A. Instruct the client to take deep, slow breaths.
• B. Administer an anti-anxiety medication.
• C. Remain with the client and offer reassurance.
• D. Encourage the client to use distraction techniques.

Correct answer: C

Rationale: During a panic attack, the priority action for the nurse is to remain with the client and offer reassurance. This helps provide a sense of safety and security, which can aid in reducing the client's anxiety. Instructing the client to take deep, slow breaths (Choice A) can be beneficial but should come after providing immediate support. Administering medication (Choice B) should not be the first intervention unless deemed necessary by the healthcare provider. Encouraging distraction techniques (Choice D) may not be as effective initially as providing direct support and reassurance.

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