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 client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:

• A. Establish an airway
• B. Call for assistance
• C. Check the client's pulse and blood pressure
• D. Perform CPR

Correct answer: A

Rationale: In a situation where a client is found unresponsive on the floor, the nurse's first priority is to establish an airway. This is crucial to ensure that the client can breathe adequately and receive oxygen. Without a patent airway, the client's oxygenation and ventilation may be compromised, leading to serious consequences. Calling for assistance is important, but establishing an airway takes precedence as it directly impacts the client's ability to breathe. Checking the client's pulse and blood pressure can be done after ensuring a clear airway. Performing CPR is not the immediate action needed unless the client's breathing and pulse are absent after the airway has been secured.

3. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

4. A client has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

• A. Inject 5 units of air into the bottle of regular insulin
• B. Withdraw the correct dose of NPH insulin from the bottle
• C. Inject 10 units of air into the bottle of NPH insulin
• D. Withdraw the correct dose of regular insulin from the bottle

Correct answer: B

Rationale: The correct order of steps for this procedure is to first inject air into the NPH insulin bottle to prevent vacuum formation. After injecting air into the NPH insulin, the next step is to withdraw the correct dose of regular insulin from its bottle. This sequence ensures that the regular insulin is drawn after the NPH insulin, preventing contamination and ensuring accurate dosing. Therefore, choice B is correct. Choices A, C, and D are incorrect because air should be injected into the NPH insulin first, not the regular insulin, and the doses should be withdrawn in the appropriate order to maintain the integrity and potency of each insulin type.

5. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?

• A. Decreased calcium
• B. Elevated potassium
• C. Increased sodium
• D. Low hemoglobin

Correct answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

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