Nursing Elites

1. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

2. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

• A. A client who has asthma.
• B. A client who has diabetes.
• C. A client who has hypertension.
• D. A client who has a history of depression.

Correct answer: A

Rationale: The correct answer is A: a client who has asthma. Essential oils have the potential to trigger asthma symptoms due to their strong scents and chemical components. Consulting with the healthcare provider is crucial before using aromatherapy with essential oils to ensure the safety and well-being of the client with asthma. Choices B, C, and D do not pose immediate risks with aromatherapy use, making them less of a priority for consultation compared to asthma. Clients with diabetes, hypertension, or depression do not have the same immediate risks associated with the use of aromatherapy as clients with asthma. However, it is still advisable for the nurse to be aware of any potential interactions or contraindications with these conditions and consult with the provider if needed.

3. A patient uses an in-the-canal hearing aid. Which assessment is a priority?

• A. Eyeglass usage
• B. Cerumen buildup
• C. Type of physical exercise
• D. Excessive moisture problems

Correct answer: B

Rationale: When a patient uses an in-the-canal hearing aid, cerumen buildup is a critical issue that needs to be regularly assessed. Cerumen can easily block the sound passage and affect the functionality of the hearing aid. Assessing and managing cerumen buildup is a priority to ensure the proper functioning of the hearing aid. Eyeglass usage, type of physical exercise, and excessive moisture problems are not directly related to the specific issue of cerumen buildup in in-the-canal hearing aids, making them lower priority assessments in this context.

4. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

5. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?

• A. An x-ray shows the end of the tube above the pylorus.
• B. The tube is aspirated and contains clear gastric fluid.
• C. The tube is flushed with sterile water without resistance.
• D. The client does not cough or choke during tube insertion.

Correct answer: B

Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.

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