Nursing Elites

1. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Instruct the client to sit with the legs crossed.
• C. Administer prophylactic antibiotics.
• D. Apply sequential compression devices to the client's legs.

Correct answer: D

Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.

2. A nurse is providing discharge teaching to a client who is recovering from a myocardial infarction. Which of the following client statements indicates a need for further teaching?

• A. I will take a daily aspirin to prevent another heart attack.
• B. I should expect to experience chest pain when I exercise.
• C. I will increase my intake of saturated fats.
• D. I will participate in a cardiac rehabilitation program.

Correct answer: C

Rationale: The correct answer is C. Increasing the intake of saturated fats can raise cholesterol levels, which is not recommended after a myocardial infarction. Choices A, B, and D are all appropriate statements indicating a good understanding of post-myocardial infarction care. Taking a daily aspirin can help prevent another heart attack, experiencing chest pain with exercise is a common expectation post-myocardial infarction, and participating in a cardiac rehabilitation program is important for recovery and improving heart health.

3. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

4. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

• A. Do you understand the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a quiet place when this occurs?
• D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

5. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

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