Nursing Elites

1. A nurse is caring for a client who has deep vein thrombosis 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. Administration of acetaminophen
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

2. A nurse is reviewing the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse expect to include?

• A. Encourage group activities to promote socialization.
• B. Encourage the client to take frequent naps throughout the day.
• C. Provide the client with frequent high-calorie snacks.
• D. Promote physical activity during mealtimes to stimulate appetite.

Correct answer: C

Rationale: Providing high-calorie snacks is essential when caring for a client in the manic phase of bipolar disorder because they often have increased energy expenditure and may not eat adequately due to their heightened activity levels. Encouraging group activities (Choice A) may overwhelm the client further during this phase. Encouraging frequent naps (Choice B) contradicts the need to manage increased energy levels. Promoting physical activity during mealtimes (Choice D) may not be appropriate as it can distract the client from eating, which is crucial in meeting their nutritional needs.

3. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

4. What is the priority intervention for a patient with fluid overload?

• A. Administer diuretics
• B. Administer IV fluids
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

5. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
• D. Set up the sterile field 5 cm below waist level.

Correct answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

Similar Questions