Nursing Elites

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

• A. Chest pain.
• B. Muscle spasms.
• C. Cool, moist skin.
• D. Incisional pain.

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

2. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

• A. Check your oxygen equipment daily for proper function.
• B. Increase the oxygen flow rate if you feel short of breath.
• C. Store your oxygen tanks lying flat on the floor.
• D. It is safe to smoke as long as you are more than 10 feet from the oxygen source.

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

3. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Massage the affected extremity to promote circulation.
• B. Elevate the affected extremity.
• C. Apply cold packs to the affected extremity.
• D. Perform range-of-motion exercises on the affected extremity.

Correct answer: C

Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.

4. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?

• A. Potassium level 4.2 mEq/L
• B. Apical pulse 58/min
• C. Digoxin level 1 ng/ml
• D. Constipation for 2 days

Correct answer: B

Rationale: The correct answer is B. An apical pulse below 60/min indicates bradycardia, a potential sign of digoxin toxicity. The nurse should report this finding to the provider for further evaluation and possible adjustment of the digoxin dose. Choice A, a potassium level of 4.2 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not indicate toxicity. Choice C, a digoxin level of 1 ng/ml, is within the therapeutic range (0.5-2 ng/ml) and is not suggestive of toxicity. Choice D, constipation for 2 days, is not directly related to digoxin administration and would not require an immediate report to the provider.

5. The healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

• A. Hyperthyroidism
• B. Thrombophlebitis
• C. Diverticulosis
• D. Hypocalcemia

Correct answer: B

Rationale: Thrombophlebitis is a condition characterized by inflammation of a vein, which increases the risk of blood clots. The use of oral contraceptives further elevates the risk of clot formation, making them contraindicated in individuals with thrombophlebitis. Hyperthyroidism (Choice A), diverticulosis (Choice C), and hypocalcemia (Choice D) are not contraindications to the use of oral contraceptives.

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