Nursing Elites

1. How should a healthcare provider monitor a patient with suspected deep vein thrombosis (DVT)?

• A. Monitor for leg swelling
• B. Encourage ambulation
• C. Check for redness
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct way for a healthcare provider to monitor a patient with suspected deep vein thrombosis (DVT) is to check for leg swelling. Leg swelling is a common symptom of DVT and monitoring for this sign is crucial for early detection and intervention. Encouraging ambulation may be beneficial for preventing DVT but is not the recommended method for monitoring an existing condition. Checking for redness may be useful in cases of superficial thrombophlebitis but is not specific to DVT. Monitoring oxygen saturation is more relevant for respiratory or cardiovascular conditions, not for DVT.

2. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 2 minutes with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase the oxytocin infusion.
• B. Maintain the oxytocin infusion.
• C. Discontinue the oxytocin infusion.
• D. Provide reassurance to the client.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. With contractions occurring every 2 minutes and lasting 90 seconds, this pattern indicates hyperstimulation, which can be harmful to the fetus. Discontinuing the oxytocin infusion is essential to prevent further harm. Increasing the oxytocin infusion would exacerbate the situation, maintaining it would continue the risk, and providing reassurance to the client, although important, does not address the need for immediate action to ensure the safety of the fetus.

3. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

4. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

• A. Administer the injection into the muscle of your thigh.
• B. Pinch the skin before inserting the needle.
• C. Rub the injection site after administering the medication.
• D. Administer the injection into the fat tissue of your abdomen.

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

5. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administering the medication.
• B. Insert the needle at a 45° angle.
• C. Use a Z-track technique to administer the injection.
• D. Aspirate for blood before injecting the medication.

Correct answer: C

Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.

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