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. Avoid massaging the affected extremity to relieve pain
• C. Avoid applying cold packs to the client's affected extremity
• D. Elevate the client's affected extremity when in bed

Correct answer: D

Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.

2. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?

• A. Below-the-knee amputation.
• B. Fractured tibia.
• C. 95% full-thickness body burn.
• D. 10 cm laceration to the forearm.

Correct answer: A

Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.

3. A nurse is teaching a client who has heart failure about a new prescription for furosemide. Which of the following statements should the nurse include?

• A. You should take this medication in the morning to reduce urination during the day.
• B. You may experience ringing in your ears as a side effect.
• C. This medication may cause your potassium level to decrease.
• D. You should consume foods high in potassium while taking this medication.

Correct answer: C

Rationale: The correct statement to include when teaching a client about furosemide is that it may cause potassium levels to decrease. Furosemide is a loop diuretic that can lead to hypokalemia, emphasizing the importance of monitoring potassium levels. Option A is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Option B is incorrect as tinnitus, not ringing in the ears, is associated with furosemide use. Option D is wrong because while it is essential to monitor potassium levels, the client should be advised to consume foods high in potassium to prevent hypokalemia.

4. A client with type 2 diabetes mellitus is scheduled for an arteriogram. Which of the following medications should the nurse instruct the client to discontinue 48 hours prior to the procedure?

• A. Atorvastatin
• B. Digoxin
• C. Nifedipine
• D. Metformin

Correct answer: D

Rationale: The correct answer is D, Metformin. Metformin should be discontinued 48 hours before an arteriogram due to the risk of lactic acidosis. Atorvastatin (Choice A) is a statin used to lower cholesterol levels and is not typically contraindicated before an arteriogram. Digoxin (Choice B) is a medication used for heart conditions and does not need to be discontinued before an arteriogram. Nifedipine (Choice C) is a calcium channel blocker used to treat high blood pressure and angina, and it is not necessary to discontinue before the procedure.

5. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

• A. Prime the IV tubing with 0.9% sodium chloride.
• B. Verify the client's blood type and Rh factor.
• C. Administer the blood over 8 hours.
• D. Use a 22-gauge needle for venous access.

Correct answer: B

Rationale: The correct answer is to verify the client's blood type and Rh factor. This action is crucial to ensure that the correct blood is administered, matching the client's blood type and Rh factor, which helps prevent transfusion reactions. Priming the IV tubing with 0.9% sodium chloride (Choice A) is not directly related to ensuring the correct blood product is administered. Administering the blood over 8 hours (Choice C) is not the standard practice for packed RBCs, which are usually given over a shorter period. Using a 22-gauge needle for venous access (Choice D) is not specific to the preparation for administering packed RBCs.

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