Nursing Elites

1. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?

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

Correct answer: A

Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.

2. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer to the client?

• A. Tomato soup
• B. Apple juice
• C. Chicken broth
• D. Cranberry juice

Correct answer: C

Rationale: The correct answer is C, Chicken broth. A clear liquid diet includes clear fluids and foods that are liquid at room temperature. Chicken broth is allowed on a clear liquid diet as it is a clear liquid, while tomato soup, apple juice, and cranberry juice are not clear liquids. Tomato soup is a thicker substance and not allowed on a clear liquid diet. Apple juice and cranberry juice are also not clear liquids because they contain pulp and are not transparent like broth.

3. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.

5. A healthcare provider is providing discharge instructions to a client with type 2 diabetes mellitus. Which resource should the healthcare provider provide?

• A. Personal blogs about managing the adverse effects of diabetes medications.
• B. Food label recommendations from the Institute of Medicine.
• C. Diabetes medication information from the Physicians' Desk Reference.
• D. Food exchange lists for meal planning from the American Diabetes Association.

Correct answer: D

Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for structured meal planning in individuals with diabetes. These lists categorize foods based on macronutrient content and help individuals plan balanced meals to manage blood sugar levels effectively. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations from the Institute of Medicine are important but may not be as specific to meal planning for diabetes. Diabetes medication information is crucial but not the primary focus when providing dietary instructions.

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