Nursing Elites

1. A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Massage the affected extremity every 2 hours.
• B. Encourage the patient to ambulate as soon as possible.
• C. Apply warm compresses to the affected extremity.
• D. Elevate the affected extremity.

Correct answer: D

Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.

2. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

3. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse should identify that which of the following findings is a manifestation of opioid toxicity?

• A. Bradypnea.
• B. Tachycardia.
• C. Hypertension.
• D. Diaphoresis.

Correct answer: A

Rationale: Corrected Rationale: Bradypnea, or slow breathing, is a common sign of opioid toxicity. When a client is experiencing opioid toxicity, the respiratory system is usually the most affected, leading to a decrease in the respiratory rate (bradypnea). Tachycardia (increased heart rate), hypertension (high blood pressure), and diaphoresis (excessive sweating) are not typical manifestations of opioid toxicity. Therefore, the correct answer is bradypnea.

4. A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?

• A. Serum calcium level
• B. Platelet count
• C. INR
• D. WBC count

Correct answer: C

Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.

5. How should a healthcare professional administer a subcutaneous injection?

• A. Insert the needle at a 45-degree angle
• B. Insert the needle at a 90-degree angle
• C. Use a Z-track method
• D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

Similar Questions