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. What is the best intervention for a patient presenting with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.

3. A healthcare professional is caring for a client who has a prescription for enoxaparin. Which of the following laboratory tests should the healthcare professional review before administering the medication?

• A. Prothrombin time (PT)
• B. INR
• C. Platelet count
• D. Potassium levels

Correct answer: D

Rationale: Corrected Rationale: Before administering enoxaparin, it is essential to review potassium levels to monitor for potential imbalances. Enoxaparin, a type of anticoagulant, does not directly affect PT, INR, or platelet count. Monitoring potassium levels is crucial to ensure the safety and effectiveness of the medication. PT and INR are typically used to monitor warfarin therapy, while platelet count is essential for assessing clotting function but is not directly related to enoxaparin administration.

4. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

5. A client with chronic kidney disease is being educated by a nurse about dietary modifications. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of potassium-rich foods.
• B. I will limit my protein intake to prevent further kidney damage.
• C. I will avoid consuming foods high in phosphorus.
• D. I will increase my intake of dairy products to support kidney function.

Correct answer: B

Rationale: The correct answer is B. Limiting protein intake is crucial for clients with chronic kidney disease as it helps prevent further kidney damage. Increasing intake of potassium-rich foods (choice A) is not recommended for clients with kidney disease as high potassium levels can be harmful. Avoiding foods high in phosphorus (choice C) is important, but limiting protein intake is a higher priority. Increasing dairy product intake (choice D) is not ideal for clients with kidney disease as they may need to monitor their phosphorus intake from such foods.

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