Nursing Elites

1. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply sequential compression devices to the client's legs.
• D. Administer anticoagulants as prescribed.

Correct answer: C

Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.

2. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hours following surgery.
• B. Give cromolyn nebulizer solution every 6 hours.
• C. Apply a warm compress to the operative site every 4 hours.
• D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

3. What is the priority nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Perform a neurological exam

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

4. A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Inject air into the vial before withdrawing the insulin.
• B. Draw up the short-acting insulin first, then the long-acting insulin.
• C. Store unopened insulin vials in the freezer.
• D. Rotate injection sites within the same anatomical region.

Correct answer: D

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.

5. A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

• A. Denial
• B. Bargaining
• C. Acceptance
• D. Anger

Correct answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

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