Nursing Elites

1. A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?

• A. Maintain the client on bed rest
• B. Apply warm, moist compresses to the legs
• C. Encourage early ambulation
• D. Massage the legs daily

Correct answer: C

Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.

2. The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?

• A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
• B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
• C. Make her responsible for the consequences of her drinking behaviors
• D. Include her in family activities whether she is drinking or sober

Correct answer: C

Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.

3. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

4. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

• A. Bladder palpation
• B. Inspection of the mouth
• C. Blood glucose monitoring
• D. Auscultation of breath sounds

Correct answer: B

Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.

5. The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?

• A. Administer the 20 Units of Humulin R subcutaneously as prescribed
• B. Ask the girl if she will be eating her breakfast this morning
• C. Discuss changing the insulin prescription to Lispro with the healthcare provider
• D. Explain to the mother the importance of eating the scheduled meals

Correct answer: B

Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.

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