Nursing Elites

1. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

• A. Avoid ambulation to prevent injury
• B. Use compression stockings
• C. Use a heating pad for comfort
• D. Elevate the client's legs on a pillow

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

2. A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?

• A. Limit sodium intake to 2 grams per day
• B. Increase fluid intake to 2 liters per day
• C. Avoid potassium-rich foods
• D. Avoid alcohol consumption

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.

3. A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the IV infusion
• C. Apply a cold compress
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

4. A client is found on the floor experiencing a seizure. What is the nurse's priority action?

• A. Apply oxygen
• B. Place the client on their side
• C. Administer an anticonvulsant
• D. Notify the provider

Correct answer: B

Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.

5. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?

• A. Decrease potassium intake
• B. Increase fluid intake to 2 liters per day
• C. Avoid foods high in calcium
• D. Increase sodium intake

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

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