Nursing Elites

1. A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?

• A. Swelling of the affected limb.
• B. Diminished peripheral pulses.
• C. Coolness of the affected limb.
• D. Redness and warmth of the affected limb.

Correct answer: D

Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.

2. When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?

• A. Shake the inhaler before use.
• B. Inhale quickly and deeply.
• C. Use the inhaler as needed.
• D. Do not use a spacer with the inhaler.

Correct answer: A

Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.

3. A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?

• A. Hypotension
• B. Bradycardia
• C. Crackles in the lungs
• D. Dry mucous membranes

Correct answer: C

Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients. Choices A, B, and D are incorrect because in fluid volume excess, hypervolemia leads to increased blood pressure (not hypotension), compensatory tachycardia (not bradycardia), and moist mucous membranes (not dry).

4. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

5. A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Vastus lateralis muscle
• D. Rectus femoris muscle

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

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