Nursing Elites

1. A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?

• A. Confirm the client's perception of the event.
• B. Notify the client's support system.
• C. Help the client identify personal strengths.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.

2. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

• A. Keep the catheter clamped when not in use
• B. Have the client perform the Valsalva maneuver while the catheter is removed
• C. Use a non-coring needle to access the catheter
• D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.

3. A client with iron-deficiency anemia is being taught about dietary management by a nurse. Which of the following foods should the nurse recommend?

• A. Oatmeal
• B. Red meat
• C. Bananas
• D. Whole grains

Correct answer: B

Rationale: The correct answer is B: Red meat. Red meat is a good dietary source of heme iron, which is easily absorbed by the body and beneficial for individuals with iron-deficiency anemia. Oatmeal, bananas, and whole grains are not as rich in iron compared to red meat and may not provide sufficient amounts to help manage iron-deficiency anemia effectively.

4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid aspirin while taking this medication.
• B. I will increase my intake of green leafy vegetables.
• C. I will take this medication with an antacid.
• D. I should expect mild bruising around my elbows.

Correct answer: A

Rationale: The correct answer is A: "I will avoid aspirin while taking this medication." Clients taking warfarin should avoid aspirin due to the increased risk of bleeding. Choice B is incorrect because increasing the intake of green leafy vegetables high in Vitamin K can interfere with the effects of warfarin. Choice C is incorrect because warfarin should not be taken with antacids as they can decrease its absorption. Choice D is incorrect because mild bruising is a common side effect of warfarin due to its anticoagulant properties.

5. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.

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