Nursing Elites

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

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

2. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?

• A. Confront the client about this behavior
• B. Express sympathy for the client's situation
• C. Speak assertively to the client
• D. Stand within 30 cm (1 ft) of the client when speaking with them

Correct answer: C

Rationale: In this situation, speaking assertively is the most appropriate action for the nurse to take. Confronting the client may escalate the situation further. Expressing sympathy, although important in other contexts, may not be effective in managing aggressive behavior. Standing within close proximity to an aggressive client can compromise the nurse's safety. Therefore, speaking assertively helps to set clear boundaries and manage the situation while ensuring safety in a seclusion room.

3. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

4. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. Calf tenderness.
• B. Shortness of breath.
• C. Elevated blood pressure.
• D. Respiratory rate of 18/min.

Correct answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

5. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

• A. Obtain the client's vital signs.
• B. Ensure the client's IV access is patent.
• C. Prime the IV tubing with 0.9% sodium chloride.
• D. Verify the client's identity.

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

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