Nursing Elites

1. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?

• A. Administer prescribed anticoagulant.
• B. Notify the healthcare provider.
• C. Auscultate lung sounds.
• D. Prepare for chest physiotherapy.

Correct answer: A

Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.

2. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?

• A. Monitor the client’s oxygen saturation level.
• B. Check the client’s heart rate and blood pressure.
• C. Evaluate the client’s level of consciousness.
• D. Assess the client's chest pain severity using a pain scale.

Correct answer: B

Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.

3. The nurse is preparing to administer a subcutaneous injection to a thin, elderly client. What is the most appropriate site for the injection?

• A. Dorsal aspect of the upper arm.
• B. Upper outer thigh.
• C. Lower abdomen.
• D. Lateral aspect of the upper arm.

Correct answer: B

Rationale: The correct answer is the upper outer thigh. In thin, elderly clients, the upper outer thigh is a recommended site for subcutaneous injections due to the presence of adequate subcutaneous tissue and muscle mass. The dorsal aspect of the upper arm may not provide enough subcutaneous tissue for proper absorption of the medication. The lower abdomen is not ideal for thin individuals as it may lead to injection into muscle rather than subcutaneous tissue. The lateral aspect of the upper arm is also not a commonly recommended site for subcutaneous injections.

4. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

• A. Begin ambulation as soon as possible.
• B. Use continuous passive motion therapy to maintain joint mobility.
• C. Avoid putting weight on the affected leg.
• D. Apply ice packs to reduce pain and swelling.

Correct answer: B

Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.

5. A client with a head injury reports severe nausea. What is the nurse's priority action?

• A. Administer anti-nausea medication as prescribed.
• B. Prepare the client for a CT scan.
• C. Elevate the head of the bed and provide an emesis basin.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.

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