Nursing Elites

1. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

• A. Use elastic stockings continuously
• B. Encourage range of motion and ambulation
• C. Massage the legs twice daily
• D. Place pillows under the knees

Correct answer: B

Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.

2. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not already completed, would take priority over the others?

• A. Place the patient in a 90-degree position
• B. Assess whether the patient is taking diuretics
• C. Obtain and attach defibrillator leads
• D. Assess the patient's last ejection fraction

Correct answer: C

Rationale: In this scenario, the elevated Troponin T level indicates cardiac damage, possibly due to a myocardial infarction. A Troponin T value of 5.3 ng/mL is significantly elevated (normal levels are below 0.2 ng/mL), suggesting acute cardiac injury. Given the setting of an Emergency Room and the critical nature of the situation, the priority intervention should be to obtain and attach defibrillator leads. Elevated Troponin T levels can indicate a higher risk of arrhythmias, including ventricular fibrillation, which can lead to sudden cardiac arrest. Defibrillator leads are essential for monitoring the patient's cardiac rhythm and readiness for immediate defibrillation if necessary. Placing the patient in a 90-degree position (Choice A) or assessing diuretic use (Choice B) are not immediate priorities in this critical situation. Additionally, assessing the patient's last ejection fraction (Choice D) is important but not as urgent as preparing for potential life-threatening arrhythmias requiring defibrillation.

3. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

• A. The patient states he had a manic episode a week ago
• B. The patient states he has been having diarrhea every day
• C. The patient presents as severely depressed
• D. The patient has a rash and pruritus on his arms and legs

Correct answer: B

Rationale: The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.

4. A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?

• A. Immobilize the cervical area to prevent further injury
• B. Monitor the patient's level of consciousness to prevent neurologic deterioration
• C. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
• D. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing

Correct answer: D

Rationale: The correct answer is to facilitate tissue perfusion to the spinal cord while maintaining airway and breathing. In the acute phase of a spinal cord injury, ensuring proper tissue perfusion to the spinal cord is crucial to prevent further damage. Maintaining airway, breathing, and circulation is essential in guiding the overall care for a patient with a spinal cord injury. Choices A, B, and C, while important in certain aspects of care, are not the overarching principles that guide the immediate management of a suspected spinal cord injury.

5. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?

• A. Cracks in the corners of the mouth
• B. Peeling skin from the tongue and gums
• C. Increased dental caries
• D. Dry mouth

Correct answer: D

Rationale: Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.

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