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. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

3. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse plan to administer?

• A. Lorazepam
• B. Atenolol
• C. Naltrexone
• D. Methadone

Correct answer: A

Rationale: Lorazepam is the correct choice for managing acute alcohol withdrawal symptoms due to its effectiveness in controlling agitation and tremors associated with this condition. Atenolol (Choice B) is a beta-blocker mainly used for hypertension and angina, not for alcohol withdrawal symptoms. Naltrexone (Choice C) is used for alcohol dependence treatment by reducing cravings and the rewarding effects of alcohol, but it is not typically used in acute withdrawal situations. Methadone (Choice D) is an opioid agonist mainly used for opioid detoxification and maintenance therapy, not for alcohol withdrawal.

4. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate 68/min.
• B. Blood pressure 110/70 mm Hg.
• C. Vision changes.
• D. Respiratory rate 18/min.

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

5. A client is starting therapy with a statin medication. Which of the following instructions should the nurse include?

• A. Take the medication on an empty stomach.
• B. Avoid consuming grapefruit juice.
• C. Increase intake of dietary fiber.
• D. Take the medication in the morning.

Correct answer: B

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming grapefruit juice when taking statin medication. Grapefruit juice can interfere with the metabolism of statins, leading to an increased risk of adverse effects. Taking the medication on an empty stomach (Choice A) or in the morning (Choice D) is not specifically necessary for statins. While increasing dietary fiber intake (Choice C) is generally beneficial for health, it is not a specific instruction related to taking statin medication.

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