Nursing Elites

1. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?

• A. Emphasize the importance of active foot flexion
• B. Check the surgical dressing
• C. Complete an incident report
• D. Explain the use of an incentive spirometer every 2 hours

Correct answer: A

Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.

2. A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?

• A. Check the client’s calcium levels.
• B. Administer a dose of calcium gluconate.
• C. Assess the client's incision site for bleeding.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.

3. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

4. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

5. A post-operative client is prescribed sequential compression devices (SCDs) while on bed rest. What is the primary purpose of this device?

• A. To prevent deep vein thrombosis (DVT).
• B. To improve circulation in the legs.
• C. To prevent pressure ulcers.
• D. To alleviate post-operative pain.

Correct answer: A

Rationale: The correct answer is A: 'To prevent deep vein thrombosis (DVT).' Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs and reducing venous stasis, which is a common risk for post-operative clients who are on bed rest. While SCDs do improve circulation in the legs indirectly, their primary purpose is DVT prevention. Preventing pressure ulcers is typically achieved through repositioning and support surfaces, not with SCDs, making choice C incorrect. SCDs are not used to alleviate post-operative pain, so choice D is also incorrect.

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