Nursing Elites

1. The healthcare professional is assisting in the care of a client diagnosed with deep vein thrombosis (DVT). Which instruction should be reinforced to prevent complications?

• A. Elevate the affected leg using pillows.
• B. Perform leg exercises while sitting.
• C. Wear snug compression stockings.
• D. Avoid applying ice packs to injuries.

Correct answer: A

Rationale: Elevating the affected leg using pillows is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promote venous return, thereby decreasing the risk of complications such as pulmonary embolism. This position aids in improving blood circulation and preventing blood clots from forming or worsening in the affected leg. Performing leg exercises while sitting might increase the risk of dislodging a blood clot. While snug compression stockings are beneficial, the primary focus should be on elevation. Avoiding ice packs on injuries is unrelated to DVT management.

2. A client is admitted with coronary artery disease (CAD) and reports dyspnea at rest. What is the nurse's priority intervention?

• A. Elevate the head of the bed.
• B. Administer oxygen.
• C. Perform continuous ECG monitoring.
• D. Apply a nasal cannula.

Correct answer: A

Rationale: The nurse's priority intervention for a client with coronary artery disease (CAD) experiencing dyspnea at rest is to elevate the head of the bed. Elevating the head of the bed helps improve lung expansion and reduces the workload on the heart, aiding in respiratory effort and cardiac function. This intervention is crucial in enhancing oxygenation and optimizing cardiac output in individuals with CAD presenting with dyspnea. Administering oxygen (Choice B) is important but elevating the head of the bed takes precedence as it directly addresses the client's respiratory distress. Continuous ECG monitoring (Choice C) and applying a nasal cannula (Choice D) are relevant interventions but not the priority when a client with CAD reports dyspnea at rest.

3. A client is being taught about the use of an albuterol inhaler. Which of the following instructions should be included?

• A. Use the inhaler every 4 hours around the clock.
• B. Shake the inhaler well before use.
• C. Rinse your mouth with water after each use.
• D. Use the inhaler while lying down.

Correct answer: B

Rationale: Shaking the inhaler well before use is a crucial step in ensuring proper medication delivery. This action helps disperse the medication evenly within the device, optimizing the effectiveness of each dose. It ensures that the client receives the intended amount of medication. The other options are incorrect: Option A suggests a fixed time interval for inhaler use, which may not be suitable for all clients and can lead to overuse. Option C, rinsing the mouth, is more relevant for corticosteroid inhalers to prevent oral thrush. Option D, using the inhaler while lying down, is not recommended as it may lead to improper drug delivery and is not the correct position for inhaler use.

4. The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?

• A. Clear lung sounds
• B. Increased peripheral pulses
• C. Bibasilar crackles
• D. Improved activity tolerance

Correct answer: C

Rationale: Bibasilar crackles are abnormal lung sounds that indicate fluid accumulation in the lungs, a sign that left-sided heart failure is worsening. This finding suggests that the client's condition is deteriorating and requires prompt intervention to prevent further complications. Clear lung sounds (Choice A) are normal and would not indicate worsening heart failure. Increased peripheral pulses (Choice B) may be seen in conditions like anxiety or exercise, but not specifically in worsening left-sided heart failure. Improved activity tolerance (Choice D) would be a positive sign, not an indicator of worsening heart failure.

5. After returning the client to bed following a cardiac catheterization procedure with the left femoral vessel as the access site, the nurse places a sign above the bed instructing the client to remain on bed rest and in which position?

• A. In semi-Fowler's position
• B. With the head of the bed elevated 45 degrees
• C. With the head of the bed elevated no more than 15 degrees
• D. With the foot of the bed elevated as much as tolerated by the client

Correct answer: C

Rationale: After cardiac catheterization via the femoral vessel, it is crucial to keep the head of the bed elevated no more than 15 degrees to prevent bleeding at the access site. This position helps maintain pressure on the femoral artery, reducing the risk of bleeding and complications post-procedure. Choices A, B, and D are incorrect because they do not provide the necessary pressure on the femoral artery to prevent bleeding, which is essential after a cardiac catheterization procedure with a femoral access site.

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