Nursing Elites

1. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.

2. A client is 1 day postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent respiratory complications?

• A. Instruct the client to avoid deep breathing exercises
• B. Encourage the use of an incentive spirometer
• C. Assist the client with ambulation every 2 hours
• D. Apply sequential compression devices (SCDs)

Correct answer: B

Rationale: Encouraging the use of an incentive spirometer is crucial for preventing respiratory complications postoperatively, such as atelectasis. Instructing the client to avoid deep breathing exercises (choice A) is incorrect as deep breathing exercises help prevent respiratory complications. Assisting with ambulation every 2 hours (choice C) is important for preventing other postoperative complications but not specifically respiratory ones. Applying sequential compression devices (SCDs) (choice D) is beneficial for preventing deep vein thrombosis but not directly related to respiratory complications.

3. A nurse is caring for a client who is receiving radiation therapy for breast cancer. Which of the following skin care instructions should the nurse provide?

• A. Wear loose clothing over the radiation site.
• B. Use scented lotions to moisturize the skin.
• C. Apply ice packs to the radiation site for pain relief.
• D. Expose the radiation site to sunlight for 20 minutes daily.

Correct answer: A

Rationale: The correct answer is A: Wear loose clothing over the radiation site. Clients receiving radiation therapy should wear loose clothing over the treatment area to prevent irritation and promote healing. Choice B is incorrect as scented lotions can irritate the skin during radiation therapy. Choice C is incorrect because ice packs should not be applied to the radiation site as they can exacerbate skin reactions. Choice D is incorrect as exposing the radiation site to sunlight can increase skin damage and should be avoided.

4. What is the most important nursing action when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

5. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

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