Nursing Elites

1. The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?

• A. Measure the circumference of the left leg.
• B. Assess for signs of bleeding, such as bruising or hematuria.
• C. Monitor the client's vital signs.
• D. Monitor the client's respiratory status.

Correct answer: B

Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.

2. After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

• A. I will not take this drug with food or milk.
• B. If I suspect pregnancy, I will discontinue the drug.
• C. An orange color in my urine should not alarm me.
• D. I will consume two glasses of cranberry juice daily.

Correct answer: C

Rationale: The correct answer is C. Phenazopyridine commonly discolors urine to a deep reddish orange, which can be mistaken for blood. It is important for the client to understand that this color change is an expected side effect and should not be a cause for alarm. Additionally, the urine can stain clothing. There are no dietary restrictions or precautions related to food or milk intake while taking phenazopyridine. Stopping the medication if suspecting pregnancy is not necessary as phenazopyridine is safe to use during pregnancy. Drinking cranberry juice is not directly related to the use of phenazopyridine and is not a specific instruction given for managing bacterial cystitis.

3. The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy?

• A. The biopsy will confirm the diagnosis of Hodgkin's disease.
• B. The biopsy will show the extent of the disease in the bones.
• C. The biopsy will be done to check for infection in the bones.
• D. The biopsy will help determine the best treatment for the disease.

Correct answer: D

Rationale: A bone marrow biopsy helps determine the best treatment plan for Hodgkin's disease by providing crucial information about the extent and nature of the disease. While confirming the diagnosis is important, the primary purpose of the biopsy in this case is to guide treatment decisions. The biopsy is not primarily for assessing the extent of the disease in the bones or checking for infections in the bones.

4. When a young client being taught to use an inhaler for asthma symptoms states the intention to use the inhaler but plans to continue smoking cigarettes, what is the best initial action by the nurse?

• A. Inform the healthcare provider of the client's statement.
• B. Explain that denial of illness can interfere with the treatment regimen.
• C. Revise the plan of care based on the client's plans to continue smoking.
• D. Review factors surrounding the client's beliefs about smoking cessation.

Correct answer: B

Rationale: The best initial action by the nurse when a client expresses plans to use an inhaler for asthma symptoms but continue smoking cigarettes is to address denial. By explaining that denial of illness can interfere with the treatment regimen, the nurse educates the client about the impact of smoking on asthma treatment. This approach helps the client understand the importance of smoking cessation in managing asthma symptoms. Informing the healthcare provider (Choice A) may be necessary but is not the initial action in this scenario. Revising the plan of care (Choice C) should be considered after addressing the client's denial and educating them. Reviewing factors surrounding the client's beliefs about smoking cessation (Choice D) is relevant but not the best initial action when denial is identified.

5. Which of the following interventions is most appropriate for a patient with acute pancreatitis?

• A. Administering oral fluids.
• B. Administering IV fluids.
• C. Administering analgesics.
• D. Encouraging the patient to ambulate.

Correct answer: B

Rationale: The most appropriate intervention for a patient with acute pancreatitis is administering IV fluids. IV fluid administration is crucial in managing acute pancreatitis as it helps maintain hydration, correct electrolyte imbalances, and prevent shock. Administering oral fluids (Choice A) may not be sufficient to address the fluid loss and maintain hydration in these patients. While analgesics (Choice C) are important for pain management in pancreatitis, addressing hydration and shock prevention takes precedence. Encouraging the patient to ambulate (Choice D) may be beneficial in some cases for preventing complications like deep vein thrombosis, but it is not the primary intervention needed in the acute phase of pancreatitis.

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