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. A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?

• A. Carrots
• B. Broccoli
• C. Chicken
• D. Bananas

Correct answer: B

Rationale: The correct answer is B: Broccoli. Broccoli is rich in calcium and is a suitable food to recommend to clients with osteoporosis to increase their calcium intake. Carrots, chicken, and bananas are not as high in calcium content compared to broccoli and therefore not the most appropriate choices for increasing calcium intake in clients with osteoporosis.

3. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

4. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Hyperkalemia
• B. Hyperglycemia
• C. Hypokalemia
• D. Hyponatremia

Correct answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Furosemide is a loop diuretic that can lead to potassium depletion (hypokalemia) due to increased urinary excretion of potassium. This can result in adverse effects such as muscle weakness, cardiac dysrhythmias, and other complications. Hyperkalemia (choice A) is not an adverse effect of furosemide but rather an elevated potassium level. Hyperglycemia (choice B) and hyponatremia (choice D) are not typically associated with furosemide use. Therefore, monitoring potassium levels and addressing hypokalemia is crucial in clients taking furosemide.

5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Massage the affected extremity to promote circulation.
• B. Elevate the affected extremity.
• C. Apply cold packs to the affected extremity.
• D. Perform range-of-motion exercises on the affected extremity.

Correct answer: C

Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.

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