Nursing Elites

1. What is the most important intervention for a patient with suspected DVT?

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

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.

2. What is the best intervention for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Provide bronchodilators
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient with respiratory distress because it helps improve oxygenation levels and alleviates respiratory distress directly. Providing oxygen addresses the primary issue of inadequate oxygen supply, which is crucial in managing respiratory distress. Repositioning the patient, while important for airway clearance, may not address the immediate need for oxygen. Providing bronchodilators and humidified air can be beneficial in certain respiratory conditions, but when a patient is in respiratory distress, ensuring adequate oxygenation through oxygen administration takes precedence.

3. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 20/min
• B. Blood pressure of 118/76 mm Hg
• C. Heart rate of 88/min
• D. Oxygen saturation of 94%

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.

4. A nurse is providing care for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?

• A. Psychologist
• B. Social worker
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, clients often experience swallowing difficulties, known as dysphagia. A speech-language pathologist specializes in assessing and managing these swallowing problems, making them the nurse's priority referral in this case. A psychologist primarily focuses on mental health and emotional well-being, which may not be the most critical issue at this stage. Social workers assist with social support and resources, while occupational therapists help with activities of daily living and mobility, which are important but not the priority when dysphagia is a concern.

5. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

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