Nursing Elites

1. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?

• A. Calf swelling
• B. Elevated blood pressure
• C. Decreased urine output
• D. Generalized rash

Correct answer: A

Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.

2. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?

• A. Examine the mouth first
• B. Reassure the child
• C. Examine the mouth last
• D. Offer a pacifier

Correct answer: C

Rationale: In this scenario, it is crucial to prioritize the comfort of the child. By examining the mouth last, discomfort is minimized, and the child is given the opportunity to settle down. Choosing to examine the mouth first may escalate the distress of the child further. While reassuring the child is important, in this case, addressing the physical discomfort before providing emotional reassurance is more effective. Offering a pacifier may provide some comfort, but addressing the immediate physical discomfort by examining the mouth last is the most appropriate action to help the child settle down after the procedure.

3. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?

• A. Tea
• B. Water
• C. Milk
• D. Soda

Correct answer: B

Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.

4. A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse’s priority?

• A. Ensure that the client signs the consent form.
• B. Lock the client’s valuables in a secure location.
• C. Verify the client’s lab values in the medical record.
• D. Administer the prescribed preoperative sedative.

Correct answer: A

Rationale: The nurse’s priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client’s right to make decisions about their care.

5. A client who is post-op following a partial colectomy has an NG tube set on low continuous suction. The client complains of a sore throat and asks when the NG tube will be removed. Which response by the nurse is appropriate at this time?

• A. When the GI tract is working again, in about three to five days, the tube can be removed.
• B. The tube will be removed once your nausea improves.
• C. You can expect the tube to be removed in about a week.
• D. The tube will be removed once the drainage stops.

Correct answer: A

Rationale: The correct response is A: 'When the GI tract is working again, in about three to five days, the tube can be removed.' After a partial colectomy, the GI tract needs time to recover and start functioning properly. The NG tube is typically removed when peristalsis returns, indicating GI function restoration, which usually occurs within 3-5 days post-op. Choice B is incorrect because the removal of the NG tube is not solely based on nausea improvement. Choice C is incorrect as it provides a longer duration for tube removal than is usually necessary. Choice D is incorrect as the cessation of drainage alone does not dictate NG tube removal; the return of GI function is the primary indicator.

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