Nursing Elites

1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

• A. Position the client with the affected extremity lower than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

2. A nurse in a clinic is caring for a patient who has a UTI. What prescription should the nurse verify with a provider?

• A. Ciprofloxacin
• B. Trimethoprim-sulfamethoxazole
• C. Oxybutynin
• D. Nitrofurantoin

Correct answer: C

Rationale: The correct answer is C: Oxybutynin. Oxybutynin is an anticholinergic used to treat overactive bladder, not a UTI. The nurse should verify this prescription because it may not be appropriate for a UTI. Choices A, B, and D are antibiotics commonly used in the treatment of UTIs. Ciprofloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin are more suitable choices for the treatment of a UTI compared to oxybutynin.

3. A client is being taught about the use of digoxin. Which of the following should be included?

• A. Monitor for low blood pressure
• B. It can cause bradycardia
• C. Take it with calcium supplements
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is B: 'It can cause bradycardia.' Digoxin can cause bradycardia as one of its side effects. Clients should be educated about this potential effect and instructed to monitor their heart rate before taking the medication. Choice A is incorrect because digoxin is more likely to cause arrhythmias than low blood pressure. Choice C is incorrect as calcium supplements can interfere with the absorption of digoxin. Choice D is incorrect as digoxin has various side effects, and clients should be aware of them.

4. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

• A. An irregularly shaped, nontender lump palpable in the right breast
• B. Tenderness present during menstruation
• C. Bilateral, symmetrical lumps that move with palpation
• D. The client reports breast tenderness before menstruation

Correct answer: A

Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.

5. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

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