Nursing Elites

1. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?

• A. Encourage the patient to drink plenty of fluids.
• B. Encourage early ambulation and leg exercises.
• C. Administer anticoagulants as prescribed.
• D. Apply compression stockings to the patient's legs.

Correct answer: B

Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.

2. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?

• A. Restrict the client's fluid intake for 4 hours following the procedure
• B. Apply cold compresses to the puncture site after the procedure
• C. Instruct the client to increase oral fluid intake after the procedure
• D. Keep the client in a prone position for 12 hours after the procedure

Correct answer: C

Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.

3. 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.

4. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

5. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will mix the medication with applesauce
• B. I will provide a snack with the medication
• C. I will store the medication in the refrigerator
• D. I will swab the inside of my child's mouth with the medication

Correct answer: D

Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.

Similar Questions