Nursing Elites

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

• A. Limit the client's fluid intake to 1500 mL per day.
• B. Avoid massaging the affected extremity to relieve pain.
• C. Do not apply cold packs to the client's affected extremity.
• D. Elevate the client's affected extremity when in bed.

Correct answer: D

Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.

2. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

• A. Increased shortness of breath.
• B. Weight gain of 2.3 kg (5 lb).
• C. Clear lung sounds.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate a therapeutic effect of furosemide, as the medication helps reduce fluid overload in heart failure. Choice A, increased shortness of breath, is incorrect as furosemide is used to relieve symptoms like shortness of breath. Choice B, weight gain of 2.3 kg (5 lb), is incorrect as furosemide is a diuretic that helps reduce fluid retention leading to weight loss. Choice D, bounding pulse, is incorrect as furosemide does not directly impact the pulse rate.

3. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

4. A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?

• A. I can clean the cat's litter box during pregnancy.
• B. I can visit someone with the flu after receiving the vaccine.
• C. I should take antibiotics for viral infections.
• D. I should wash my hands after gardening.

Correct answer: C

Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.

5. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.

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