Nursing Elites

1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

• A. Position the client with the affected extremity lower than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

2. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

3. A patient is receiving chemotherapy and reports nausea. Which of the following dietary recommendations should the nurse make?

• A. Eat foods served hot
• B. Drink liquids between meals
• C. Eat dry cereal
• D. Choose foods with a strong aroma

Correct answer: C

Rationale: The correct recommendation for a patient receiving chemotherapy and experiencing nausea is to suggest eating dry, bland foods like cereal. These types of foods are often better tolerated as they are less likely to trigger nausea compared to aromatic or hot foods. Drinking liquids between meals, as suggested in option B, can be helpful to prevent dehydration but may not specifically address the nausea. Eating foods with a strong aroma, as in option D, may actually worsen nausea in patients undergoing chemotherapy.

4. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

• A. Remove blood-saturated dressings
• B. Apply clean dressings over the saturated ones and hold pressure
• C. Elevate the wound above heart level
• D. Leave the wound open to air

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

5. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsened with breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.

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