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. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?

• A. Administer a high-flow oxygen mask.
• B. Position the client in a high-Fowler's position.
• C. Provide a high-carbohydrate diet.
• D. Encourage the client to cough and deep breathe.

Correct answer: B

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.

4. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

5. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?

• A. Place a 4x4 wick in the stoma opening
• B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
• C. Cut the bag opening to the measurement of the stoma size
• D. Administer a PRN antidiarrheal agent

Correct answer: C

Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.

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