Nursing Elites

1. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client’s fluid intake to 1500 mL per day
• B. Massage the affected extremity to relieve pain
• C. Apply cold packs to the affected extremity
• D. Elevate the client’s affected extremity when in bed

Correct answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

2. A healthcare professional is assessing a client with hepatic encephalopathy. Which of the following foods indicates understanding of dietary teaching?

• A. Cottage cheese
• B. Tuna salad
• C. Rice with black beans
• D. Three-egg omelet

Correct answer: C

Rationale: The correct answer is C: 'Rice with black beans.' Plant-based proteins such as beans are recommended for clients with hepatic encephalopathy to reduce ammonia production from animal proteins. Cottage cheese (choice A), tuna salad (choice B), and a three-egg omelet (choice D) are high in animal proteins, which can contribute to increased ammonia levels in hepatic encephalopathy, making them less suitable dietary choices for these clients.

3. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

• A. Administer antiseizure medications promptly.
• B. Use oral airway devices during seizures.
• C. Pad the side rails of the bed.
• D. Apply restraints during the seizure to prevent injury.

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

4. A nurse is reviewing the ABG results of a client with chronic emphysema. Which result suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.

5. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

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