Nursing Elites

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

• A. Encourage the client to remain on bed rest.
• B. Massage the client's legs every 4 hours.
• 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 take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (Choice A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (Choice B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (Choice D) is a treatment for DVT, it is not a preventive measure for a client at risk.

2. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?

• A. Lochia that is red and contains small clots.
• B. Fundus firm at the umbilicus.
• C. Fundus deviated to the right.
• D. Moderate perineal pain with swelling.

Correct answer: C

Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.

3. A client has a new prescription for captopril. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. You may experience a persistent dry cough.
• C. Increase your intake of foods high in potassium.
• D. You should avoid eating grapefruit while taking this medication.

Correct answer: B

Rationale: The correct answer is B. A persistent dry cough is a common side effect of captopril, an ACE inhibitor, and should be included in the teaching. Choice A is incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can increase potassium levels, so there is no need to further increase potassium intake. Choice D is incorrect because captopril does not interact with grapefruit.

4. A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?

• A. Speak louder to help the client understand
• B. Speak using simple sentences and gestures
• C. Use a picture board to facilitate communication
• D. Have the client practice writing words down

Correct answer: C

Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.

5. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

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