Nursing Elites

1. A client who is 14 weeks of gestation reports swelling of the face. What should the nurse do next?

• A. Administer an analgesic.
• B. Report this finding to the provider immediately.
• C. Administer an antiemetic.
• D. Monitor the client's vital signs.

Correct answer: B

Rationale: The correct answer is to report this finding to the provider immediately. Swelling of the face in pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Prompt reporting and intervention are crucial to prevent complications for both the client and the fetus. Administering an analgesic (choice A) is not appropriate for this situation as it does not address the underlying cause of the swelling. Administering an antiemetic (choice C) is used to treat nausea and vomiting, which are not the primary concerns associated with facial swelling in this scenario. Monitoring the client's vital signs (choice D) is important but should be done after reporting the finding to the provider to guide further assessment and management.

2. What is the most important nursing assessment for a patient with suspected deep vein thrombosis (DVT)?

• A. Check for leg pain
• B. Perform Homan's sign test
• C. Monitor for redness
• D. Assess for warmth and swelling

Correct answer: A

Rationale: The most important nursing assessment for a patient with suspected deep vein thrombosis (DVT) is to check for leg pain. Leg pain is a cardinal symptom of DVT and is often the initial indicator of a blood clot. While assessing for warmth, swelling, and redness are also important in DVT evaluation, leg pain is the most crucial as it can prompt further diagnostic testing and interventions. Performing Homan's sign test is no longer recommended due to its low specificity and potential to dislodge a clot, causing complications. Monitoring for redness is important but may not always be present in DVT cases. Assessing for warmth and swelling is relevant but still secondary to the assessment of leg pain in suspected DVT cases.

3. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

4. A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?

• A. Place the infant on their stomach to sleep.
• B. Place the infant on their side to sleep.
• C. Place the infant on their back to sleep.
• D. Allow the infant to sleep with a pacifier.

Correct answer: C

Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.

5. How should a healthcare professional respond to a patient who is experiencing confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Encourage deep breathing exercises
• D. Perform a neurological exam

Correct answer: A

Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.

Similar Questions