Nursing Elites

1. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

2. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?

• A. Decrease the oxytocin infusion
• B. Discontinue the oxytocin infusion
• C. Increase the IV fluid rate
• D. Apply an internal fetal monitor

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.

3. A client with hepatic encephalopathy is being cared for by a nurse. Which food selection indicates the client understands dietary teaching?

• A. A sandwich and milkshake
• B. Rice with black beans
• C. Cottage cheese and tuna lettuce
• D. Three-egg omelet with low-sodium ham

Correct answer: B

Rationale: For clients with hepatic encephalopathy, foods high in protein like cottage cheese and tuna should be avoided. Plant-based protein sources like beans are recommended due to their lower ammonia production during digestion. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they include high-protein or high-sodium foods that can worsen the condition of hepatic encephalopathy.

4. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?

• A. Report of fatigue and fever
• B. Report of muscle twitching and skin rash
• C. Report of blurred vision
• D. Report of nasal congestion

Correct answer: B

Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.

5. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

• A. 90-degree angle
• B. 60-degree angle
• C. 75-degree angle
• D. 45-degree angle

Correct answer: A

Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.

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