Nursing Elites

1. A client with a deep vein thrombosis (DVT) is prescribed enoxaparin. What teaching should the nurse provide?

• A. Rotate injection sites to prevent bruising.
• B. Administer the injection in the abdomen only.
• C. Report any unusual bleeding or bruising.
• D. Avoid contact sports to prevent injury.

Correct answer: C

Rationale: The correct teaching for a client prescribed enoxaparin for deep vein thrombosis (DVT) is to report any unusual bleeding or bruising. Enoxaparin is an anticoagulant, and these symptoms could indicate excessive anticoagulation. Choice A is incorrect because with enoxaparin, injections are usually given in the abdomen, not rotated to different sites. Choice D is not directly related to the medication but is a general precaution for individuals at risk of injury.

2. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?

• A. Evaluate the closest proximal pulse.
• B. Observe color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.

3. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

• A. Encourage bed rest to prevent strain on the hip
• B. Assist the client with early ambulation
• C. Provide continuous passive motion therapy
• D. Administer pain medication before activity

Correct answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

4. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

5. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

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