Nursing Elites

1. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administration of acetaminophen
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

2. A client has a new prescription for levothyroxine. Which of the following findings should the nurse monitor for as a potential adverse effect of the medication?

• A. Increased heart rate.
• B. Weight loss.
• C. Hyperthermia.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: Corrected Rationale: An increased heart rate is a common adverse effect of levothyroxine due to its role in boosting metabolism. Choice B, weight loss, is actually a therapeutic effect of levothyroxine as it helps in managing hypothyroidism by increasing the metabolic rate. Hyperthermia (Choice C) is not a typical adverse effect of levothyroxine. Decreased deep-tendon reflexes (Choice D) are not associated with levothyroxine use.

3. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

• A. Limit sodium intake to no more than 1,500 mg per day.
• B. Exercise for at least 150 minutes each week.
• C. Avoid all dairy products.
• D. Limit intake of all carbohydrates.

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

4. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

5. A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?

• A. Bananas
• B. Fish
• C. White bread
• D. Chicken breast

Correct answer: D

Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.

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