Nursing Elites

1. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Position the client with the affected leg below the heart
• B. Massage the affected extremity every 4 hours
• C. Apply cold compresses to the affected extremity
• D. Elevate the affected leg while in bed

Correct answer: D

Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.

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 nurse is caring for a client prescribed gabapentin. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Renal function
• C. Blood glucose levels
• D. Cardiac rhythm

Correct answer: B

Rationale: The correct answer is B: Renal function. Gabapentin is primarily eliminated by the kidneys, so monitoring renal function is essential to ensure the drug is being cleared effectively from the body. Monitoring liver function tests (choice A) is not a priority for gabapentin as it is not primarily metabolized by the liver. Blood glucose levels (choice C) are not directly impacted by gabapentin. Cardiac rhythm (choice D) monitoring is not typically necessary for clients on gabapentin unless they have pre-existing cardiac conditions that may be exacerbated by the medication.

4. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?

• A. Notify the provider.
• B. Report the incident to the risk manager.
• C. Check the condition of the patient.
• D. Complete an incident report.

Correct answer: C

Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.

5. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

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