Nursing Elites

1. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

• A. Localized warmth
• B. Calf pain
• C. Swelling in the affected leg
• D. Hematuria

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

2. Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?

• A. Fresh fruit and vegetables
• B. Foods sweetened with aspartame
• C. Bread with honey
• D. Gluten-rich bread

Correct answer: B

Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.

3. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Blood glucose 90 mg/dL
• B. Sodium 138 mEq/L
• C. Total calcium 5.0 mg/dL
• D. Potassium 4.2 mEq/L

Correct answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

4. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

• A. Breath sounds are audible bilaterally
• B. Mist is visible in the T-piece
• C. Pulse oximetry of 88
• D. Client is unable to verbalize

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

5. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

• A. Encourage discussion about feelings of limb loss.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer assistance to move to a quiet room to relax.

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

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