Nursing Elites

1. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Massage the affected extremity to promote circulation.
• B. Elevate the affected extremity.
• C. Apply cold packs to the affected extremity.
• D. Perform range-of-motion exercises on the affected extremity.

Correct answer: C

Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.

2. A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?

• A. Bananas
• B. Fish
• C. White bread
• D. Chicken breast

Correct answer: D

Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.

3. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

4. A healthcare provider is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the healthcare provider to delegate?

• A. Adjusting the flow rate of the client's oxygen tank.
• B. Collecting a urine sample.
• C. Measuring the client's pain level.
• D. Transporting a client to x-ray.

Correct answer: D

Rationale: The correct answer is 'D: Transporting a client to x-ray.' This task is appropriate for delegation to assistive personnel as it involves transferring the client safely from one location to another, which does not require the specialized skills of a healthcare provider. Adjusting the flow rate of the client's oxygen tank (Choice A) involves making clinical decisions that should be done by a licensed healthcare provider. Collecting a urine sample (Choice B) and measuring the client's pain level (Choice C) require critical thinking and assessment skills that are typically within the scope of practice of licensed healthcare providers, not assistive personnel.

5. A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min
• B. Oxygen saturation of 95%
• C. Urine output of 30 mL/hr
• D. Serosanguineous wound drainage

Correct answer: C

Rationale: In a postoperative client, a urine output of 30 mL/hr is a concerning finding as it indicates oliguria, which may suggest dehydration or kidney impairment. Adequate urine output is essential for monitoring renal function and overall fluid status. A heart rate of 78/min is within the normal range for an adult. An oxygen saturation of 95% is acceptable and indicates adequate oxygenation. Serosanguineous wound drainage is expected in the early postoperative period and is not a cause for immediate concern unless it becomes excessive or changes character.

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