Nursing Elites

1. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.

2. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Use a heating pad to warm your feet.
• D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

3. While caring for a client with an arterial line, which of the following actions should the nurse take?

• A. Level the transducer with the client's phlebotomy site
• B. Flush the arterial line every 8 hours
• C. Obtain a blood sample for arterial blood gases
• D. Keep the client's hand elevated above the heart level

Correct answer: C

Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.

4. A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?

• A. Ammonia 75 mcg/dL
• B. Sodium 142 mEq/L
• C. Calcium 9.5 mg/dL
• D. Bilirubin 2.5 mg/dL

Correct answer: D

Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.

5. When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?

• A. I will take my medication only when I feel dizzy.
• B. I will check my blood pressure at least once a week.
• C. I will stop taking my medication once my blood pressure is within normal range.
• D. I will sit quietly for 5 minutes before measuring my blood pressure.

Correct answer: D

Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.

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