Nursing Elites

1. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left lower extremity. Which of the following findings should the nurse expect?

• A. Pain in the right lower extremity
• B. Cold skin in the affected extremity
• C. Redness and warmth in the affected extremity
• D. Shiny skin on the affected extremity

Correct answer: C

Rationale: Corrected Rationale: Redness and warmth are classic signs of inflammation, which are commonly seen in clients with deep vein thrombosis (DVT). These findings indicate increased blood flow and temperature in the affected area. Pain in the right lower extremity (Choice A) is not expected in a client with DVT affecting the left lower extremity. Cold skin (Choice B) is not a typical finding in DVT; instead, warmth is more indicative of inflammation. Shiny skin (Choice D) is not a common characteristic of DVT; rather, the skin may appear red, swollen, and warm due to the inflammatory process.

2. A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.

3. A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?

• A. Increased urine output
• B. Increased serum sodium
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: C

Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.

4. A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?

• A. Fundus firm and at the umbilicus.
• B. Heart rate 80/min.
• C. Blood pressure 130/78 mm Hg.
• D. A constant trickle of bright red blood from the vagina.

Correct answer: D

Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.

5. A client post-thyroidectomy reports tingling in their lips and fingers. The nurse should identify this finding as an indication of which of the following complications?

• A. Hypokalemia
• B. Hypocalcemia
• C. Hyponatremia
• D. Hyperglycemia

Correct answer: B

Rationale: Tingling in the lips and fingers is a classic sign of hypocalcemia, which can occur as a complication following a thyroidectomy due to inadvertent damage to the parathyroid glands that regulate calcium levels. Hypokalemia (Choice A) presents with muscle weakness and cardiac issues, not tingling. Hyponatremia (Choice C) typically manifests with confusion, seizures, and muscle cramps. Hyperglycemia (Choice D) is associated with increased thirst, frequent urination, and fatigue.

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