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 in a mental health unit is planning room assignments for four clients. Which of the following clients should be closest to the nurse's station?

• A. A client who has an anxiety disorder and is experiencing moderate anxiety.
• B. A client who has somatic symptom disorder and reports chronic pain.
• C. A client who has depressive disorder and reports feeling hopeless.
• D. A client who has bipolar disorder and impaired social interactions.

Correct answer: D

Rationale: A client with bipolar disorder and impaired social interactions should be placed closest to the nurse's station for closer monitoring. Clients with bipolar disorder may experience mood swings, including manic episodes that can lead to impulsive behaviors or aggression. Placing such a client near the nurse's station allows for quick intervention and monitoring of their social interactions, especially if they are impaired. The other options, such as anxiety disorder, somatic symptom disorder, and depressive disorder, do not inherently require immediate proximity to the nurse's station based on the information provided.

3. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?

• A. INR 2.0
• B. Platelet count 150,000/mm3
• C. aPTT 60 seconds
• D. WBC count 8,000/mm3

Correct answer: C

Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.

4. A nurse is caring for a client who is receiving packed RBCs. Which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every hour
• B. Administer the blood using a microdrip set
• C. Assess the client's vital signs every 2 hours
• D. Infuse the blood within 4 hours

Correct answer: D

Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.

5. How should a healthcare provider manage a patient with chronic kidney disease?

• A. Limit fluid intake
• B. Increase potassium intake
• C. Provide a high-protein diet
• D. Administer IV antibiotics

Correct answer: A

Rationale: Limiting fluid intake is essential in managing patients with chronic kidney disease to prevent fluid overload, which can worsen kidney function. Increasing potassium intake is not recommended as patients with kidney disease often need to limit potassium. Providing a high-protein diet may put extra strain on the kidneys, so it is not ideal. Administering IV antibiotics is not a standard treatment for chronic kidney disease.

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