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. What is the first step a healthcare professional should take when preparing to provide tracheostomy care?

• A. Perform hand hygiene
• B. Gather equipment
• C. Explain the procedure
• D. Assess the client

Correct answer: A

Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.

3. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

• A. Decreased subcutaneous fat
• B. Muscle atrophy
• C. Pressure injury
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

4. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?

• A. Ensure the client wears a mask when outside the room if there is construction nearby.
• B. Place the client in a private room with positive pressure airflow.
• C. Restrict all visitors from seeing the client.
• D. Provide a HEPA filter in the client's room.

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.

5. A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

• A. Help the client take sips of water to promote insertion of the NG tube.
• B. Insert the tube without asking the client to swallow.
• C. Advance the tube continuously without pausing.
• D. Use a large-bore tube for insertion.

Correct answer: A

Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.

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