Nursing Elites

1. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?

• A. Walk 15 to 20 minutes three (3) times a day.
• B. Keep the legs in the dependent position when sitting.
• C. Remove compression bandages before going to bed.
• D. Perform Berger-Allen exercises (4) times a day.

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking is beneficial as it helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B is incorrect because keeping the legs in the dependent position when sitting can lead to increased venous pressure, worsening varicose veins. Choice C is incorrect as compression bandages should typically be worn continuously, especially during the initial healing phase. Choice D is incorrect as Berger-Allen exercises are not commonly associated with post-sclerotherapy care.

2. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

• A. Encourage the client to drink liquids
• B. Perform active range of motion exercises
• C. Elevate the head of the bed to 45 degrees
• D. Provide a high-fiber diet to the client

Correct answer: B

Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.

3. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

• A. Deep tendon reflexes
• B. Arterial blood gases
• C. Skin turgor
• D. Capillary refill time

Correct answer: A

Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.

4. Determining whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation involves assessing the appropriateness and effectiveness of care provided to the patient. It helps determine if the care aligns with the patient's current physiological and psychological status. Choice B, Planning, refers to developing a plan of care based on assessment data. Choice C, Implementation, involves carrying out the planned interventions. Choice D, Assessment, is the initial step that involves collecting data about the patient's condition.

5. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the Clinitest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, it is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading. Choice A is incorrect as the specimen should be collected before meals for accurate results. Choice B is incorrect as it should be the Clinitest tablet, not the clingiest tablet. Choice D is incorrect as the statement is incomplete and lacks clarity.

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