Nursing Elites

1. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

• A. Massage the affected extremity
• B. Elevate the affected leg
• C. Apply cold packs to the affected leg
• D. Keep the leg dependent to increase circulation

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

2. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?

• A. Limit intake of processed foods
• B. Increase intake of fresh fruits and vegetables
• C. Use of accessory muscles
• D. Monitor for allergic reactions

Correct answer: A

Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.

3. A nurse is caring for a client with a prescription for duloxetine. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum electrolytes
• C. Blood glucose
• D. Potassium levels

Correct answer: A

Rationale: The correct answer is A) Liver function. Duloxetine can affect liver function, making it crucial for the nurse to monitor liver function tests. Monitoring serum electrolytes (choice B), blood glucose (choice C), or potassium levels (choice D) is not directly associated with duloxetine use and would not be the priority in this case.

4. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client’s fluid intake to 1500 mL per day
• B. Massage the affected extremity to relieve pain
• C. Apply cold packs to the affected extremity
• D. Elevate the client’s affected extremity when in bed

Correct answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

5. A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

• A. Estrogen causes increased appetite
• B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
• C. HCG hormone leads to increased gastric acidity
• D. The uterus compresses the stomach early in pregnancy

Correct answer: B

Rationale: The correct answer is B. Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This relaxation allows stomach acid to reflux into the esophagus, leading to heartburn during pregnancy. Choices A, C, and D are incorrect because they do not directly relate to the physiological mechanism that causes heartburn during pregnancy. Estrogen causing increased appetite (Choice A) is not directly linked to heartburn. HCG hormone increasing gastric acidity (Choice C) is not the primary cause of heartburn during pregnancy. The uterus compressing the stomach early in pregnancy (Choice D) may contribute to feelings of fullness or bloating but is not the main cause of heartburn.

Similar Questions