Nursing Elites

1. The healthcare provider is caring for a client with a history of deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with a history of deep vein thrombosis (DVT) because it could indicate a pulmonary embolism. A pulmonary embolism is a serious complication of DVT where a blood clot travels to the lungs and can be life-threatening. Immediate medical attention is required to prevent further complications. Pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT itself but do not pose the same level of immediate danger as the potential for a pulmonary embolism.

2. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife’s previous marriage. How should the nurse identify this family form?

• A. Extended
• B. Blended
• C. Nuclear
• D. Alternative

Correct answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.

3. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

• A. Notify the manufacturer
• B. Disconnect the machine, and measure the blood pressure manually every 15 min
• C. Adjust the machine settings again
• D. Ignore the extra readings

Correct answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

4. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

• A. Sit on the toilet 30 minutes after eating a meal.
• B. Increase your fluid intake to help with bowel movements.
• C. Exercise regularly to improve bowel function.
• D. Consume more high-fiber foods to prevent constipation.

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

5. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

• A. Diffuse expiratory wheezing
• B. Loose, productive cough
• C. No relief from inhaler
• D. Fever and chills

Correct answer: A

Rationale: During an acute asthma attack, one of the expected assessments by the nurse would be diffuse expiratory wheezing. This occurs due to narrowed airways and increased airflow velocity. Choice B, a loose productive cough, is not typically associated with an asthma attack. Choice C, no relief from inhaler, may indicate ineffective treatment but is not a direct assessment finding related to the physical examination. Choice D, fever and chills, are not typical symptoms of an asthma attack and would not be expected findings during the initial assessment of an acute asthma attack.

Similar Questions