Nursing Elites

1. A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection, the nurse plans to arrange to increase the client's intake of:

• A. Vitamin C and Zinc
• B. Vitamin B12 and Calcium
• C. Vitamin D and Iron
• D. Vitamin A and Potassium

Correct answer: A

Rationale: The correct answer is A: Vitamin C and Zinc. Vitamin C is essential for collagen synthesis, which is important for wound healing. Zinc plays a crucial role in immune function and also aids in wound healing. Vitamin B12 and Calcium (Choice B) are not directly associated with wound healing properties. Vitamin D and Iron (Choice C) are important for overall health but are not specifically targeted for wound healing. Vitamin A and Potassium (Choice D) do not have direct wound healing properties and are not the best choices to promote wound healing and fight infection.

2. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?

• A. Make sure two fingers can fit under the sleeve.
• B. Apply the sleeve tightly to prevent blood clots.
• C. Ensure the sleeve is snug and comfortable.
• D. Check that the sleeve is loose enough to avoid constriction.

Correct answer: A

Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.

3. While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

• A. Remove the restraints one at a time
• B. Secure the restraints tightly to prevent movement
• C. Check the restraints every hour
• D. Use leather restraints for additional security

Correct answer: A

Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.

4. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the LPN/LVN monitor closely while the client is taking this medication?

• A. Blood glucose level
• B. Prothrombin time (PT) and INR
• C. Serum potassium level
• D. Serum creatinine level

Correct answer: B

Rationale: The LPN/LVN should closely monitor Prothrombin time (PT) and INR (Choice B) levels in a client receiving warfarin. These values are crucial to ensure the medication's effectiveness and prevent complications like bleeding. Monitoring blood glucose level (Choice A) is not directly relevant to warfarin therapy. While serum potassium level (Choice C) and serum creatinine level (Choice D) are important for other conditions or medications, they are not specifically required to be monitored when a client is on warfarin.

5. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?

• A. Normal breathing sounds
• B. Wheezing
• C. Crackles
• D. Stridor

Correct answer: A

Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.

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