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 assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

3. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?

• A. Pregabalin
• B. Lorazepam
• C. Colchicine
• D. Codeine

Correct answer: A

Rationale: The correct answer is A: Pregabalin. Pregabalin is a first-line medication for treating pain in clients with fibromyalgia. It works by decreasing the number of pain signals sent out by damaged nerves. Choice B, Lorazepam, is a benzodiazepine used for anxiety and not indicated for fibromyalgia pain. Choice C, Colchicine, is used to treat gout by reducing inflammation and not indicated for fibromyalgia. Choice D, Codeine, is an opioid analgesic that is not typically recommended for fibromyalgia due to concerns about tolerance and dependence.

4. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?

• A. Place the client in a negative pressure room
• B. Wear an N95 respirator mask when entering the room
• C. Wear a gown and gloves when providing care to the client
• D. Place a face mask on the client

Correct answer: C

Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.

5. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

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