Nursing Elites

1. The nurse is assessing a client with a suspected diagnosis of deep vein thrombosis (DVT). Which clinical sign is most indicative of DVT?

• A. Redness and warmth over the affected area
• B. Decreased peripheral pulses
• C. Cyanosis of the toes
• D. Muscle cramps in the calf

Correct answer: A

Rationale: Corrected Rationale: Redness and warmth over the affected area are classic signs of inflammation, which commonly occur in deep vein thrombosis (DVT) due to the obstruction of blood flow. These symptoms result from the body's inflammatory response to the blood clot. Choices B, C, and D are less indicative of DVT. Decreased peripheral pulses may occur in arterial insufficiency rather than DVT. Cyanosis of the toes indicates decreased oxygenation and is more characteristic of arterial issues. Muscle cramps in the calf are nonspecific and can be caused by various conditions, not solely DVT.

2. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?

• A. It helps reduce the production of intestinal gases.
• B. It ensures clearer imaging by emptying the stomach.
• C. It prevents the risk of aspiration during the procedure.
• D. It is a standard procedure for all surgical interventions.

Correct answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

3. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?

• A. Avoid driving for at least 2 weeks
• B. Resume a low-fat diet
• C. Remove the bandages from the incision after 24 hours
• D. Expect significant pain for the first week

Correct answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

4. A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?

• A. Starting an exercise program
• B. Keeping a sleep diary
• C. Practicing relaxation techniques before bed
• D. Using sleep-inducing medications at night

Correct answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

5. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?

• A. Check blood pressure
• B. Assess heart rate
• C. Monitor respiratory rate
• D. Measure oxygen saturation

Correct answer: B

Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.

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