Nursing Elites

1. The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which finding supports this diagnosis?

• A. Positive Homan's sign.
• B. Unilateral leg swelling.
• C. Bilateral calf pain.
• D. Redness and warmth in the affected leg.

Correct answer: D

Rationale: The correct answer is D: Redness and warmth in the affected leg. These are classic signs of deep vein thrombosis (DVT) and support the diagnosis. Choice A, Positive Homan's sign, is an outdated and unreliable test for DVT, so it is not the best choice. Choice B, Unilateral leg swelling, can be seen in DVT but is less specific compared to redness and warmth. Choice C, Bilateral calf pain, is not a typical finding in DVT, as the pain in DVT is usually unilateral.

2. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?

• A. Elevate the affected leg on a pillow.
• B. Apply a warm compress to the affected leg.
• C. Perform passive range-of-motion exercises on the affected leg.
• D. Encourage the client to ambulate frequently.

Correct answer: A

Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.

3. When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?

• A. Participate in an exercise program for 6 weeks
• B. Obtain blood pressure daily for 2 weeks
• C. Increase dietary intake of omega-3 fatty acids
• D. Begin a low sodium diet immediately

Correct answer: D

Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.

4. A client with a history of asthma is admitted with shortness of breath. Which assessment finding requires immediate intervention?

• A. Expiratory wheezes.
• B. Increased respiratory rate.
• C. Absence of breath sounds.
• D. Frequent coughing.

Correct answer: C

Rationale: The correct answer is C: Absence of breath sounds. This finding is concerning in a client with asthma as it may indicate a severe asthma exacerbation, airway obstruction, or pneumothorax, all of which require immediate intervention. Absence of breath sounds suggests a lack of airflow in the lungs, which is a critical sign that should prompt immediate action. Expiratory wheezes (choice A) are common in asthma and may not warrant immediate intervention unless severe. An increased respiratory rate (choice B) is expected in a client with asthma experiencing shortness of breath, but it does not indicate an immediate threat to the airway. Frequent coughing (choice D) is a common symptom in asthma exacerbations but does not signify an immediate need for intervention as it can be managed with appropriate asthma treatments.

5. A client with a history of chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?

• A. Hemoglobin of 12 g/dL.
• B. Reticulocyte count of 1%.
• C. Blood pressure of 130/80 mm Hg.
• D. Serum ferritin level of 100 ng/mL.

Correct answer: A

Rationale: The correct answer is A. A hemoglobin level of 12 g/dL is an indicator of effective erythropoietin therapy as it shows an increase in red blood cell production. Reticulocyte count (choice B) reflects the bone marrow's response to anemia but does not directly confirm the effectiveness of erythropoietin therapy. Blood pressure (choice C) and serum ferritin level (choice D) are not specific indicators of the effectiveness of erythropoietin therapy for chronic kidney disease.

Similar Questions