Nursing Elites

1. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?

• A. Encourage physical activity to reduce withdrawal symptoms
• B. Administer diazepam to prevent seizures
• C. Monitor for signs of dehydration
• D. Encourage the client to verbalize their feelings

Correct answer: B

Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.

2. The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?

• A. Lightly rub the lower leg to check for redness and tenderness.
• B. Apply elastic stockings every 4 hours.
• C. Measure the calf circumference of both legs.
• D. Flex the foot while assessing for patient discomfort.

Correct answer: C

Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.

3. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?

• A. Increase protein intake
• B. Monitor blood glucose levels frequently
• C. Increase the dose of insulin
• D. Reduce carbohydrate intake

Correct answer: B

Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.

4. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

• A. Purulent
• B. Serous
• C. Sanguineous
• D. Serosanguineous

Correct answer: D

Rationale: The correct answer is D, serosanguineous. Serosanguineous drainage is thin, watery, and pale red, indicating a mixture of serous fluid and blood. Choice A (purulent) refers to thick, yellow or green drainage indicating infection. Choice B (serous) is thin, clear drainage. Choice C (sanguineous) is bright red, indicating fresh bleeding.

5. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

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