Nursing Elites

1. A nurse is caring for a client who has DVT. 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. Massage the affected extremity to relieve pain
• C. Apply cold packs to the affected extremity
• D. Elevate the client’s affected extremity when in bed

Correct answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

2. A charge nurse on a med-surg unit is preparing to delegate tasks to a licensed practical nurse (LPN). What task should the charge nurse delegate to the LPN?

• A. Initiate a care plan.
• B. Perform a complex wound dressing change.
• C. Administer an oral antibiotic to a patient.
• D. Complete an initial assessment.

Correct answer: C

Rationale: The correct task that the charge nurse should delegate to the LPN is to administer an oral antibiotic to a patient. LPNs are trained and permitted to administer medications orally under the supervision of a registered nurse. Initiating a care plan (Choice A) and completing an initial assessment (Choice D) are tasks that typically require higher-level nursing education and critical thinking skills, which are more suitable for registered nurses. Performing a complex wound dressing change (Choice B) involves specialized skills and assessment that are often within the scope of practice of registered nurses or wound care specialists.

3. While caring for a client receiving nitroglycerin for chest pain, which of the following side effects should the nurse monitor for?

• A. Hypotension
• B. Tachycardia
• C. Bradycardia
• D. Hyperglycemia

Correct answer: A

Rationale: Corrected Rationale: Nitroglycerin is known to cause hypotension due to its vasodilating effect, which can lead to low blood pressure. Therefore, the nurse should closely monitor the client for signs of hypotension such as dizziness, light-headedness, or weakness. Tachycardia (increased heart rate), bradycardia (decreased heart rate), and hyperglycemia (high blood sugar) are not typically associated with nitroglycerin use and are less likely to be side effects that the nurse needs to monitor for in this scenario.

4. A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?

• A. Decrease intake of vitamins and supplements to every other day
• B. Eat 15 g of fiber per day
• C. Consume 48 ounces of water each day
• D. Drink hot water with lemon juice each morning

Correct answer: D

Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.

5. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

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