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 healthcare provider is preparing education material for a client. Which technique should the healthcare provider use in creating the material?

• A. Emphasize important information using bold lettering.
• B. Use a 7th-grade reading level.
• C. Avoid using cartoons in the material.
• D. Use words with three or four syllables.

Correct answer: B

Rationale: Using a 7th-grade reading level is the most effective technique when creating education material for clients because it ensures that the content is easily understood by a wide range of individuals. Option A, emphasizing important information with bold lettering, may help draw attention but doesn't guarantee comprehension. Option C, avoiding cartoons, is not necessarily a universal rule and can sometimes make material more engaging. Option D, using words with three or four syllables, can make the material more complex and harder to understand, defeating the purpose of effective communication in education material.

3. When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?

• A. Obtain the specimen immediately upon the client waking up.
• B. Wait one day to collect the specimen if the client cannot provide sputum.
• C. Ask the client to provide 15 to 20 ml of sputum.
• D. Wear sterile gloves when collecting the specimen.

Correct answer: A

Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.

4. How should a healthcare professional monitor a patient for infection post-surgery?

• A. Monitor the surgical site
• B. Monitor for fever
• C. Check blood pressure
• D. Check for redness

Correct answer: A

Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.

5. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

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