Nursing Elites

1. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?

• A. INR of 1.5
• B. Platelet count of 200,000/mm³
• C. Hemoglobin of 12 g/dL
• D. aPTT of 70 seconds

Correct answer: A

Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.

2. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

3. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?

• A. Encourage the client to apply a heating pad for 2 hours at a time
• B. Apply an ice pack to the client’s back for 1 hour
• C. Remove distractions from the client’s room
• D. Instruct the client to take deep, rhythmic breaths

Correct answer: D

Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.

4. 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.

5. Before starting an intensive exercise program, what instruction is most important for the nurse to provide to the client?

• A. Be sure to have a complete physical examination before beginning your planned exercise program.
• B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
• C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
• D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

Correct answer: A

Rationale: Before starting an intensive exercise program, it is crucial for the client to have a complete physical examination. This examination ensures that the client is physically fit to engage in such activities and helps in identifying any underlying health issues that could be exacerbated by the exercise regimen. Choice B is incorrect because it focuses on stress levels related to eating habits rather than the importance of a physical examination for safety. Choice C is incorrect as exercise and stress management classes can complement each other rather than being mutually exclusive. Choice D is incorrect as monitoring weight loss, while important, is not as critical as ensuring the client's physical readiness for the exercise program.

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