Nursing Elites

1. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

• A. Use elastic stockings continuously
• B. Encourage range of motion and ambulation
• C. Massage the legs twice daily
• D. Place pillows under the knees

Correct answer: B

Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.

2. One hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

• A. Milk the chest tube gently to remove any clots.
• B. Clamp the chest tube momentarily to check for the origin of the air leak.
• C. Assist the patient to deep breathe, cough, and use the incentive spirometer.
• D. Set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine.

Correct answer: S

Rationale: In this scenario, the best action is to set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine. The patient's pain level is high, which can hinder deep breathing and coughing. Addressing pain control is a priority to facilitate optimal respiratory function. Milking the chest tube to remove clots is unnecessary as the drainage amount is not alarming in the early postoperative period. Clamping the chest tube to locate the air leak is not recommended as it can lead to tension pneumothorax. Assisting the patient to deep breathe, cough, and use the incentive spirometer is important but should follow adequate pain management to ensure the patient can effectively participate in these activities.

3. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

• A. Oculogyric crisis
• B. Tardive dyskinesia
• C. Nystagmus
• D. Dysphagia

Correct answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

4. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

• A. The bicarbonate level (HCO3) is 31 mEq/L
• B. The arterial oxygen saturation (SaO2) is 92%
• C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg
• D. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg

Correct answer: D

Rationale: While all the values are abnormal, the low PaO2 level of 59 mm Hg indicates that the patient is at a critical point on the oxyhemoglobin dissociation curve. At this level, a small decrease in PaO2 can lead to a significant drop in oxygen saturation and compromise tissue oxygenation. Therefore, immediate intervention is necessary to improve the patient's oxygenation status. Choice A (HCO3 of 31 mEq/L) may indicate metabolic alkalosis or compensation for respiratory acidosis; however, it does not require immediate action in this scenario. Choice B (SaO2 of 92%) is slightly low but not critically low to require immediate action. Choice C (PaCO2 of 31 mm Hg) is within the normal range and does not indicate immediate danger to the patient.

5. A patient has taken an overdose of aspirin. Which of the following should a nurse closely monitor during acute management of this patient?

• A. Onset of pulmonary edema
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Parkinson's disease type symptoms

Correct answer: A

Rationale: The correct answer is to monitor the onset of pulmonary edema. In cases of aspirin overdose, metabolic acidosis is a common consequence that can lead to the development of pulmonary edema. Early signs of aspirin poisoning include symptoms like tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs may manifest as drowsiness, bizarre behavior, unsteady walking, and coma. Aspirin poisoning can cause abnormal breathing that is typically rapid and deep. Pulmonary edema may occur due to increased capillary permeability in the lungs, leading to the leakage of proteins and fluid transudation in renal and pulmonary tissues. Changes in renal tubule permeability can also affect colloid osmotic pressure, potentially contributing to pulmonary edema. Monitoring pulmonary edema is crucial in managing aspirin overdose cases to prevent further complications. Choices B, C, and D are incorrect because metabolic alkalosis, respiratory alkalosis, and Parkinson's disease type symptoms are not typically associated with aspirin overdose and are not primary concerns in its acute management.

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