Nursing Elites

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

• A. Massage the client's legs every 4 hours.
• B. Administer prophylactic antibiotics.
• C. Apply sequential compression devices to the client's legs.
• D. Encourage the client to remain on bed rest.

Correct answer: C

Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.

2. A nurse is caring for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the NG tube with 0.9% sodium chloride before feedings.
• B. Place the client in a high Fowler's position during feedings.
• C. Administer the feedings over 30 minutes.
• D. Warm the formula before administering it.

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position during enteral feedings. This position helps prevent aspiration by promoting the downward flow of the feeding and reducing the risk of regurgitation into the lungs. Choice A is incorrect because flushing the NG tube with 0.9% sodium chloride before feedings is not directly related to preventing aspiration. Choice C is incorrect because the rate of administration does not directly impact the risk of aspiration. Choice D is incorrect because warming the formula does not specifically address the prevention of aspiration during enteral feedings.

3. A nurse is providing discharge teaching to a client following a colon resection and a new colostomy. What dietary advice should the nurse provide?

• A. Avoid foods that are high in protein.
• B. Consume foods high in fiber and low in fat.
• C. Eat foods high in vitamin C to promote healing.
• D. Avoid all raw vegetables.

Correct answer: B

Rationale: The correct answer is B: Consume foods high in fiber and low in fat. Following a colon resection and a new colostomy, a high-fiber, low-fat diet is recommended to promote healing and reduce the risk of complications. Foods high in fiber help maintain bowel regularity and prevent constipation, which is crucial after this type of surgery. Choices A, C, and D are incorrect because avoiding foods high in protein, consuming foods high in vitamin C, or avoiding all raw vegetables are not the most appropriate dietary advice in this situation.

4. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

5. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?

• A. The client's urine output decreases.
• B. The client's blood pressure increases.
• C. The client's heart rate increases.
• D. The client's urine specific gravity decreases.

Correct answer: A

Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.

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