Nursing Elites

1. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

• A. Remove elastic stockings every 4 hours.
• B. Measure the calf circumference of both legs.
• C. Lightly rub the lower leg for redness and tenderness.
• D. Dorsiflex the foot while assessing for patient discomfort.

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

2. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?

• A. Check IV tubing for obstruction
• B. Increase the flow rate
• C. Change the IV site
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.

3. When caring for a client with diarrhea due to shigellosis, what precautions should the nurse implement?

• A. Wear a gown when caring for the client.
• B. Wear gloves only.
• C. Use standard precautions only.
• D. Wear a mask and face shield.

Correct answer: A

Rationale: The correct answer is to wear a gown when caring for the client. Shigellosis is highly contagious, and contact precautions are essential to prevent the spread of infection. Wearing gloves alone may not provide adequate protection as the client's diarrhea can contain infectious pathogens that can easily spread. Standard precautions include hand hygiene, but specific precautions for shigellosis require wearing a gown to protect against contact with infectious material. Wearing a mask and face shield are not necessary for shigellosis, as the primary mode of transmission is through the fecal-oral route, and these precautions are not indicated for this type of transmission.

4. A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

• A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
• B. “It’s been so stressful for me to have to depend on my child to help around the house.”
• C. “I just heard my friend Al die. That’s the third one in 3 months.”
• D. “I keep forgetting which medications I have taken during the day.”

Correct answer: C

Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.

5. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

• A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
• B. The nurse avoids discussing the client's diagnosis to prevent emotional distress.
• C. The nurse provides a vague answer about the client's condition.
• D. The nurse promises to provide information only if it is requested by the client.

Correct answer: A

Rationale: Veracity involves telling the truth, a fundamental ethical principle in healthcare. In this scenario, the nurse demonstrates veracity by responding honestly when the client directly asks about her cancer diagnosis. Choice B is incorrect as avoiding discussing the diagnosis to prevent emotional distress does not align with veracity and transparency. Choice C is incorrect as providing a vague answer does not uphold the principle of truthfulness. Choice D is incorrect because promising to provide information only upon client request does not address the immediate question about the cancer diagnosis and lacks transparency.

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