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 client has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. Avoid drinking alcohol while taking this medication.
• C. Eat 3 large meals each day.
• D. Report any muscle pain to your provider.

Correct answer: B

Rationale: The correct instruction the nurse should include for a client prescribed metformin is to avoid drinking alcohol. Alcohol consumption while on metformin increases the risk of lactic acidosis, a serious condition. Taking metformin at bedtime (choice A) is not a standard instruction. Eating 3 large meals each day (choice C) is not specific to metformin use and may not be suitable for all individuals. Reporting muscle pain (choice D) is important but not directly related to metformin use.

3. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the tube with 30 mL of water every 4 hours.
• B. Position the client on the left side during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Check gastric residual every 2 hours.

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

4. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?

• A. The client's urine output decreases.
• B. The client's blood pressure increases.
• C. The client's heart rate increases.
• D. The client's urine specific gravity decreases.

Correct answer: A

Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.

5. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?

• A. Apples.
• B. White bread.
• C. Bananas.
• D. Grapes.

Correct answer: C

Rationale: Bananas are high in potassium, which should be avoided by clients with chronic kidney disease to prevent hyperkalemia. Apples, white bread, and grapes do not have high potassium levels and are generally acceptable for clients with chronic kidney disease unless they have other specific dietary restrictions.

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