Nursing Elites

1. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?

• A. Expel any air bubbles at the top of the prefilled syringe
• B. Massage the injection site to evenly distribute the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.

2. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle modifications. Which of the following instructions should be included?

• A. Sleep with the head of the bed elevated.
• B. Avoid drinking fluids with meals.
• C. Eat three large meals each day.
• D. Lie down after eating.

Correct answer: B

Rationale: The correct instruction for a client with GERD is to avoid drinking fluids with meals. This is because consuming fluids while eating can exacerbate reflux symptoms by increasing stomach distension and contributing to the reflux of stomach contents into the esophagus. Option A is incorrect as elevating the head of the bed can help prevent reflux during sleep, not while drinking fluids. Option C is incorrect as consuming three large meals a day can worsen GERD symptoms due to increased gastric distension. Option D is incorrect as lying down after eating can also worsen GERD symptoms by promoting the reflux of stomach contents into the esophagus.

3. A client with a new diagnosis of Crohn's disease is receiving teaching from a nurse. Which statement by the client demonstrates an understanding of the teaching?

• A. I should eat more fiber to help with my bowel movements.
• B. I will need to have routine colonoscopies to monitor my condition.
• C. I will limit my intake of whole grains.
• D. I should consume a low-fat diet.

Correct answer: B

Rationale: The correct answer is B. Clients with Crohn's disease require routine colonoscopies to monitor disease progression and complications. This helps healthcare providers assess the status of the disease and make informed treatment decisions. Choice A is incorrect because while fiber may be beneficial for some digestive conditions, it can exacerbate symptoms in Crohn's disease. Choice C is incorrect as whole grains can be a good source of nutrients unless they individually trigger symptoms in the client. Choice D is also incorrect since a low-fat diet is not a specific requirement for managing Crohn's disease.

4. What is the most appropriate method to assess a patient's level of consciousness?

• A. Use the Glasgow Coma Scale
• B. Assess the patient's orientation
• C. Check pupillary response
• D. Monitor vital signs

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

5. What is the best intervention for a patient with a suspected pulmonary embolism?

• A. Administer oxygen
• B. Administer anticoagulants
• C. Reposition the patient
• D. Administer bronchodilators

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient with a suspected pulmonary embolism because it helps alleviate respiratory distress and improve oxygenation. Oxygen therapy is crucial to ensure adequate oxygen levels in the blood due to the obstruction in the pulmonary circulation caused by the embolism. Administering anticoagulants (choice B) is a treatment for confirmed pulmonary embolism rather than a suspected case. Repositioning the patient (choice C) or administering bronchodilators (choice D) would not directly address the underlying issue of impaired gas exchange and oxygen delivery associated with pulmonary embolism.

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