Nursing Elites

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

• A. Encourage the client to ambulate frequently.
• B. Apply warm, moist compresses to the affected leg.
• C. Massage the affected leg.
• D. Place the client in a supine position.

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

2. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

• A. Fever
• B. Rash
• C. Fatigue
• D. Increased appetite

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

3. A nurse is caring for a client with diabetes who is experiencing hypoglycemia. Which of the following interventions should the nurse perform first?

• A. Administer insulin
• B. Give the client a carbohydrate snack
• C. Call for assistance
• D. Monitor blood glucose

Correct answer: B

Rationale: The correct answer is to give the client a carbohydrate snack. When a client is experiencing hypoglycemia, the priority intervention is to raise their blood glucose levels quickly. Administering insulin (Choice A) would further lower the blood glucose levels and is contra-indicated in this situation. Calling for assistance (Choice C) may be necessary but is not the priority over addressing the low blood sugar. Monitoring blood glucose (Choice D) is important but not the initial action needed to raise blood glucose levels rapidly.

4. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

• A. Constricted pupils
• B. Dilated pupils
• C. Increased reflexes
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

5. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client’s skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder frequently to the client’s skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

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