Nursing Elites

1. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

• A. Raise the side rails on both sides of the client's bed during repositioning.
• B. Reposition the client without assistive devices.
• C. Discuss the client's preferences to determine a repositioning schedule.
• D. Evaluate the client's ability to help with repositioning.

Correct answer: D

Rationale: The correct answer is to evaluate the client's ability to help with repositioning. When caring for a client who had a stroke, assessing their ability to participate in repositioning is crucial for promoting safety and encouraging their involvement in their care. This evaluation helps determine the level of assistance needed and supports the client's autonomy. Option A is incorrect because raising the side rails alone does not address the client's active involvement in repositioning. Option B is incorrect as using assistive devices may be necessary for safe repositioning. Option C is incorrect as discussing preferences is important but does not directly address the client's ability to assist in repositioning.

2. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

3. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Productive cough with green sputum
• B. Temperature of 37.1°C (98.8°F)
• C. Crackles in the lung bases
• D. Oxygen saturation of 95%

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

4. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed 45 degrees during feedings.
• B. Place the client in the left lateral position for 30 minutes after feedings.
• C. Flush the tube with 30 mL of sterile water before each feeding.
• D. Check gastric residuals every 8 hours.

Correct answer: A

Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.

5. 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. Avoid massaging the affected extremity to relieve pain
• C. Avoid applying cold packs to the client's affected extremity
• D. Elevate the client's affected extremity when in bed

Correct answer: D

Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.

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