Nursing Elites

1. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Administer thrombolytics as prescribed.
• B. Massage the affected extremity every 2 hours.
• C. Apply warm compresses to the affected extremity.
• D. Place the client in a supine position with the legs elevated.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.

2. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 95%
• B. Blood pressure of 130/85 mm Hg
• C. Coughing up small amounts of sputum
• D. Absent gag reflex

Correct answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

3. A client with a new diagnosis of Crohn's disease is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?

• A. Eat foods that are high in fiber.
• B. Avoid dairy products to reduce diarrhea.
• C. Eat small, frequent meals to reduce symptoms.
• D. You should increase your intake of whole grains.

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to eat small, frequent meals to reduce symptoms of Crohn's disease. This eating pattern can help manage symptoms by reducing the workload on the digestive system. Choice A is incorrect because foods high in fiber can aggravate symptoms in Crohn's disease. Choice B is incorrect because not all individuals with Crohn's disease need to avoid dairy products, and it is not a universal recommendation. Choice D is incorrect because increasing whole grains may not be suitable for everyone with Crohn's disease, as it can worsen symptoms in some cases.

4. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Hemoglobin 12 g/dL
• C. BUN 18 mg/dL
• D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

5. A nurse is reviewing laboratory results for a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following results should the nurse report to the provider?

• A. White blood cell count 8,000/mm³
• B. Platelet count 150,000/mm³
• C. Hemoglobin 14 g/dL
• D. Aspartate aminotransferase (AST) 60 units/L

Correct answer: D

Rationale: The correct answer is D: Aspartate aminotransferase (AST) 60 units/L. An elevated AST level indicates liver damage, which can be a side effect of methotrexate and should be reported. Elevated white blood cell count (choice A), platelet count (choice B), or normal hemoglobin level (choice C) are not directly related to methotrexate therapy for rheumatoid arthritis.

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