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. A patient in the emergency room has a fractured left elbow and presents with an unequal radial pulse, swelling, and numbness in the left hand after waiting for 5 hours. What is the nurse's priority intervention?

• A. Place the patient in a supine position
• B. Ask the patient to rate his pain on a scale of 1 to 10.
• C. Wrap the fractured area with a snug dressing
• D. Start an IV in the other arm.

Correct answer: D

Rationale: The correct answer is to start an IV in the other arm. In this scenario, the patient is showing signs of Acute Compartment Syndrome, a serious condition that occurs due to increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. Starting an IV is crucial as the patient may require emergency surgery, such as a fasciotomy, to relieve the pressure and prevent further complications. Placing the patient in a supine position, asking about pain levels, or wrapping the fractured area, though important, are not the priority interventions in this critical situation where immediate medical intervention is necessary to prevent irreversible damage or loss of limb.

3. In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?

• A. Assessment
• B. Analysis
• C. Planning
• D. Implementation

Correct answer: D

Rationale: The correct answer is 'Implementation.' In the nursing process, implementation involves carrying out the planned interventions to meet the patient's goals. Encouraging the patient to attend a psychoeducational group daily is an intervention aimed at building social skills. Assessment (choice A) is the phase where data about the patient's condition is collected. Analysis (choice B) involves interpreting the gathered data. Planning (choice C) is where the nurse decides on the interventions to address the patient's needs. Therefore, in this scenario, recording the item 'Encourage patient to attend one psychoeducational group daily' would be part of the implementation phase.

4. Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?

• A. Teach the patient to avoid using over-the-counter expectorants.
• B. Assist the patient with chest physiotherapy and postural drainage.
• C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
• D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.

Correct answer: D

Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.

5. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?

• A. Do not let this prescription run out.
• B. The medication may cause gingival hyperplasia.
• C. Periodic serum drug levels are needed.
• D. Watch for excessive facial hair growth.

Correct answer: A

Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.

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