Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?

• A. Monitor for signs of bleeding, such as bruising.
• B. Monitor the client’s vital signs every hour.
• C. Monitor for pain in the affected limb.
• D. Assess for signs of pulmonary embolism, such as sudden shortness of breath.

Correct answer: D

Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.

2. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

3. An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?

• A. Antiinfectives and antidepressants.
• B. Anticoagulants and antihistamines.
• C. Antiretrovirals and antivirals.
• D. Antihypertensives and anticholinergics.

Correct answer: D

Rationale: The correct answer is D: Antihypertensives and anticholinergics. Anticholinergics are known to cause dryness of secretions, including dry eyes, which can lead to symptoms of eye dryness, itching, and excessive tearing as reported by the client. Choices A, B, and C are incorrect as they do not typically cause the symptoms described by the client. Antiinfectives, antidepressants, anticoagulants, antihistamines, antiretrovirals, and antivirals do not commonly lead to dry eyes, itching, and excessive tearing.

4. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

• A. Ask not to be assigned to this client or to work on another unit
• B. Tell the client that such behavior is inappropriate
• C. Inform the client that hospital policy prohibits staff from dating clients
• D. Discuss the boundaries of the therapeutic relationship with the client

Correct answer: D

Rationale: The correct response for the nurse in this situation is to discuss the boundaries of the therapeutic relationship with the client. By doing so, the nurse can reinforce professionalism, establish clear boundaries, and prevent ethical conflicts. Option A is incorrect because avoiding the client or unit does not address the issue at hand and may compromise patient care. Option B, while acknowledging the behavior, does not address the underlying reasons and boundaries. Option C, stating hospital policy, is not as therapeutic or client-centered as discussing the therapeutic relationship directly.

5. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

Similar Questions