Nursing Elites

1. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

• A. Apply warm compresses to the affected leg.
• B. Elevate the left leg above the level of the heart.
• C. Measure the circumference of the left leg.
• D. Administer pain medication as prescribed.

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

2. When applying an ice bag to a client's ankle following a sports injury, which of the following actions should the nurse take?

• A. Fill the bag two-thirds full with ice.
• B. Apply the ice bag directly to the skin with a barrier.
• C. Keep the ice bag on for more than 30 minutes at a time.
• D. Use a frozen gel pack instead of ice.

Correct answer: A

Rationale: Filling the ice bag two-thirds full is the correct action as it ensures the effectiveness of the ice application while allowing some space for the ice to move and conform to the injury. Choice B is incorrect because the ice bag should be applied with a barrier like a cloth to prevent direct contact with the skin, which can lead to ice burns. Choice C is wrong as ice should typically be applied for 20 minutes at a time to avoid tissue damage. Choice D is also incorrect as ice is preferred over frozen gel packs for immediate sports injury management.

3. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

4. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

• A. Cleanse the entry port prior to withdrawing urine.
• B. Use a sterile syringe to collect urine from the collection bag.
• C. Obtain the specimen from the drainage tubing.
• D. Replace the catheter before obtaining the specimen.

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

5. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

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