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 client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

• A. Monitor the client's blood pressure continuously
• B. Weigh the client daily
• C. Monitor the infusion site for signs of infiltration
• D. Measure the client's intake and output every 2 hours

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

3. What is the most effective intervention for a patient experiencing acute pain?

• A. Administer analgesics
• B. Reposition the patient
• C. Provide non-pharmacological interventions
• D. Administer IV fluids

Correct answer: A

Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.

4. A client with a new diagnosis of diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water every day to prevent dryness.
• B. Trim your toenails straight across to prevent injury.
• C. Apply lotion between your toes after bathing.
• D. Wear cotton socks to keep your feet dry.

Correct answer: B

Rationale: The correct answer is B: 'Trim your toenails straight across to prevent injury.' In clients with diabetes, trimming toenails straight across is essential to prevent ingrown toenails and injury. Choice A is incorrect because soaking feet in warm water can lead to dryness, which is not recommended for diabetic foot care. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect because although cotton socks are recommended, the primary purpose is to prevent moisture buildup, not specifically to keep the feet dry.

5. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

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