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 caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

• A. Using a night-light
• B. Demonstrating how to use the call light
• C. Placing the bedside table in close proximity
• D. Hourly rounding by the nurse

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

3. A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?

• A. Expel any air bubbles from the prefilled syringe
• B. Inject the medication in the lateral abdominal wall
• C. Massage the injection site to evenly distribute the medication
• D. Administer NSAIDs for injection site discomfort

Correct answer: B

Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.

4. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?

• A. Administer oxygen
• B. Prepare the client for a thoracentesis
• C. Elevate the client’s lower extremities
• D. Administer anticoagulant therapy

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.

5. A healthcare provider is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the healthcare provider instruct the client to increase intake during pregnancy?

• A. Vitamin E
• B. Vitamin D
• C. Fiber
• D. Calcium

Correct answer: D

Rationale: The correct answer is D: Calcium. During pregnancy, it is essential to increase calcium intake as it is crucial for fetal bone development and to prevent maternal bone loss. Adequate calcium supports the increased needs of both the mother and the developing baby. Vitamin E, Vitamin D, and fiber are also important nutrients, but the specific nutrient that needs to be increased during pregnancy for bone development is calcium. Vitamin E is an antioxidant that plays a role in protecting cells from damage, Vitamin D helps with calcium absorption and bone health, and fiber is important for digestive health but does not specifically need to be increased during pregnancy for bone development.

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