Nursing Elites

1. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

2. What is the most appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is the most appropriate nursing intervention for a patient with suspected DVT because it helps prevent further clot formation and complications. Applying compression stockings (choice B) can be a preventive measure but is not the primary intervention for treating DVT. Encouraging ambulation (choice C) is beneficial for preventing DVT but is not the immediate intervention for a suspected case. Monitoring oxygen saturation (choice D) is important for assessing respiratory function but is not the primary intervention for DVT treatment.

3. A nurse is caring 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 medication?

• A. Hemoglobin
• B. Platelet count
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: D

Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.

4. A nurse is planning care for a client who has osteoarthritis. Which of the following interventions should the nurse include?

• A. Administer opioids routinely for chronic pain.
• B. Instruct the client to avoid weight-bearing exercises.
• C. Apply heat to affected joints to reduce stiffness.
• D. Avoid physical activity to prevent joint damage.

Correct answer: C

Rationale: The correct intervention for a client with osteoarthritis is to apply heat to affected joints to reduce stiffness. Heat application helps improve circulation, relax muscles, and reduce discomfort in joints affected by osteoarthritis. Administering opioids routinely (Choice A) is not the first-line treatment for osteoarthritis and carries risks of dependency and side effects. Instructing the client to avoid weight-bearing exercises (Choice B) may lead to muscle weakness and reduced joint flexibility. Avoiding physical activity altogether (Choice D) can lead to further joint stiffness and compromised overall health.

5. How should a healthcare professional care for a patient with a central line?

• A. Flush the line daily
• B. Monitor for infection
• C. Change the dressing weekly
• D. Replace the central line every week

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is crucial. This is because central lines can introduce bacteria into the bloodstream, leading to serious infections. While flushing the line daily and changing the dressing weekly are important aspects of central line care, monitoring for infection takes precedence. Infections can occur rapidly and have severe consequences, so early detection through vigilant monitoring is key. Replacing the central line every week is not a standard practice and should only be done when clinically indicated, such as in cases of infection or malfunction.

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