Nursing Elites

1. In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?

• A. Atherosclerotic plaque formation.
• B. Stasis of blood flow.
• C. Endothelial damage.
• D. Atherosclerotic vessel changes.

Correct answer: B

Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.

2. A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?

• A. Use the inhaler only before bedtime
• B. Shake the inhaler well before use
• C. Exhale fully before inhaling the medication
• D. Take two puffs every hour

Correct answer: B

Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.

3. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?

• A. Review the last administration of IV pain medication.
• B. Administer a PRN dose of acetaminophen.
• C. Decrease IV fluids to keep the vein open (KVO) rate.
• D. Calculate total intake and output.

Correct answer: C

Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.

4. While performing a skin assessment on an older adult, the nurse notices a number of irregular round brownish-colored lesions on the client’s hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

• A. Apply a topical antibiotic ointment.
• B. Monitor the lesions for changes.
• C. Advise the client to use sunscreen.
• D. Refer the client for a skin lesion biopsy.

Correct answer: D

Rationale: Referral for a skin biopsy is necessary to rule out potential malignancy of irregular skin lesions. Applying a topical antibiotic ointment (Choice A) is not indicated for irregular pigmented lesions. Monitoring the lesions for changes (Choice B) may delay appropriate intervention if malignancy is present. Advising the client to use sunscreen (Choice C) is important for sun protection but is not the priority when irregular lesions are present.

5. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

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