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. What is the primary action when a healthcare provider discovers a patient has fallen?

• A. Assess the patient for injuries
• B. Call for help immediately
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

3. A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?

• A. Witness the waste of the controlled substance by another nurse
• B. Dispose of the controlled substance by yourself
• C. Leave the controlled substance in the client's room for later use
• D. Document the administration and sign off at the end of the shift

Correct answer: A

Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.

4. A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?

• A. Clamp the chest tube during ambulation
• B. Keep the collection chamber below the level of the chest
• C. Add sterile water to the water-seal chamber
• D. Empty the collection chamber every 12 hours

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.

5. What is the best way to monitor for infection in a patient with a central line?

• A. Check the central line site daily
• B. Monitor the patient's vital signs
• C. Check the central line dressing every other day
• D. Check for signs of sepsis

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

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