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 is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

• A. Dietitian consult
• B. Speech therapy referral
• C. Oral suction at the bedside
• D. Clear liquids

Correct answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids or pureed foods. Therefore, the nurse should clarify the prescription for clear liquids to prevent potential harm to the client. Choices A, B, and C are appropriate interventions for a client with dysphagia following a stroke. A dietitian consult can help modify the client's diet for safe swallowing, speech therapy can assist in improving swallowing function, and oral suction at the bedside helps maintain airway patency and prevents aspiration.

3. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?

• A. Ask the client if he is okay.
• B. Call security from the room.
• C. Find out if there is anyone else in the room.
• D. Ask security to make sure the room is safe.

Correct answer: D

Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.

4. The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?

• A. Prevention of plantar warts
• B. Prevention of foot fungus
• C. Prevention of neuropathy
• D. Prevention of amputation

Correct answer: D

Rationale: The correct answer is D: Prevention of amputation. Patients with diabetes are at a higher risk of foot complications, such as ulcers, infections, and ultimately, amputations. Proper foot care education aims to prevent these serious complications. Choices A, B, and C are incorrect because while they are also important aspects of foot care, the primary goal in diabetes management is to prevent severe outcomes like amputation.

5. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

• A. Check the IV tubing for obstruction
• B. Increase the infusion rate
• C. Administer a bolus of fluid
• D. Replace the IV catheter

Correct answer: A

Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.

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