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 nurse is caring for a client who has a prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

• A. Pickles
• B. Fresh vegetables
• C. Canned soup
• D. Smoked salmon

Correct answer: B

Rationale: Fresh vegetables are an excellent choice for clients on a low-sodium diet as they are naturally low in sodium. Pickles, canned soup, and smoked salmon are high in sodium and should be avoided by clients following a low-sodium diet. Pickles are pickled in a brine solution high in sodium, canned soup usually contains added salt for preservation, and smoked salmon is a processed food that typically has a high sodium content.

3. How should a healthcare provider manage a patient with chronic heart failure?

• A. Monitor daily weight
• B. Provide fluid restriction
• C. Administer diuretics
• D. Monitor intake and output

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.

4. What is the appropriate nursing intervention for a patient experiencing a suspected stroke?

• A. Administer thrombolytics
• B. Perform a neurological assessment
• C. Perform a CT scan
• D. Administer oxygen

Correct answer: B

Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.

5. A nurse is providing teaching to a client who is at 28 weeks of gestation and is scheduled for a glucose tolerance test. Which of the following instructions should the nurse include?

• A. You should avoid consuming any food or drink for 8 hours before the test.
• B. You should drink 8 oz of water 1 hour before the test.
• C. You should take an antacid before the test.
• D. You should drink a glass of milk 1 hour before the test.

Correct answer: A

Rationale: Clients should avoid consuming any food or drink for 8 hours before the glucose tolerance test to ensure accurate results. Choice A is the correct instruction for the client preparing for a glucose tolerance test. Drinking water, taking an antacid, or consuming milk before the test can interfere with the accuracy of the results. Water or any other substance might affect the concentration of glucose in the blood, leading to inaccurate test results. Antacids and milk can also interfere with the test outcome. Therefore, the client should follow the instruction to fast for 8 hours before the test.

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