Nursing Elites

1. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

2. 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.

3. When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?

• A. Cool skin at the IV insertion site
• B. Presence of fluid leaking around the IV catheter
• C. Swelling above the IV site
• D. Red streaks tracking the vein

Correct answer: D

Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.

4. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

• A. Obtain an analgesic prescription.
• B. Administer an IV fluid bolus.
• C. Administer PRN antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.

5. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?

• A. Increased sensitivity to cold.
• B. Increased heart rate and palpitations.
• C. Improved energy levels.
• D. Improved tolerance to heat.

Correct answer: B

Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.

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