Nursing Elites

1. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

2. Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?

• A. Determine the reason why the client is refusing to use the incentive spirometer.
• B. Insist that the client use the incentive spirometer.
• C. Administer pain medication to help the client use the spirometer.
• D. Document the refusal in the client’s medical record.

Correct answer: A

Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.

3. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

• A. Place a pillow under the patient's lower legs.
• B. Turn the head toward one side with a large, soft pillow.
• C. Position legs flat against the bed.
• D. Raise the head of the bed to 45 degrees.

Correct answer: A

Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.

4. The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: C

Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.

5. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

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