Nursing Elites

1. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

• A. Monitor for signs of a pulmonary embolism.
• B. Assess for signs of dehydration.
• C. Monitor for signs of compartment syndrome.
• D. Check the client’s oxygen saturation levels.

Correct answer: A

Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.

2. A client with rheumatoid arthritis has just been prescribed methotrexate. What teaching should the nurse include?

• A. Take the medication on an empty stomach.
• B. Report any signs of infection, such as a sore throat.
• C. Take folic acid supplements to prevent anemia.
• D. Use sunscreen to prevent photosensitivity.

Correct answer: D

Rationale: The correct answer is D: 'Use sunscreen to prevent photosensitivity.' Methotrexate increases photosensitivity, so clients should be advised to use sunscreen to protect their skin from sun exposure. Choice A is incorrect because methotrexate is usually taken with food to reduce gastrointestinal side effects. Choice B may be important but is not specific to methotrexate therapy. Choice C is also important, but the primary reason for folic acid supplementation with methotrexate is to reduce the risk of certain side effects like anemia rather than preventing anemia itself.

3. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

• A. Provide a detailed handout with complex terms
• B. Use simple language and visual aids
• C. Encourage the client to research the diagnosis online
• D. Incorporate medical jargon to explain the condition

Correct answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

4. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

5. A client with Type 2 diabetes is admitted with frequent hyperglycemic episodes and glycosylated hemoglobin (A1C) of 10%. What actions should the nurse include in the client's plan of care?

• A. Mixing glargine with aspart insulin to manage glucose levels.
• B. Teaching foot care to prevent injuries.
• C. Coordinating carbohydrate-controlled meals and subcutaneous injections.
• D. Reviewing site rotation for insulin injections.

Correct answer: C

Rationale: In managing a client with Type 2 diabetes experiencing frequent hyperglycemic episodes and with a high A1C level, it is crucial to coordinate carbohydrate-controlled meals and subcutaneous injections. This approach helps regulate blood glucose levels effectively. Mixing glargine with aspart insulin (Choice A) is not a recommended practice as these insulins have different onset and peak times. Teaching foot care (Choice B) is important in diabetes management but is not the priority in this scenario. Reviewing site rotation for insulin injections (Choice D) is important to prevent lipodystrophy but is not the immediate action needed to address the client's hyperglycemia and high A1C level.

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