Nursing Elites

1. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?

• A. Apply compression therapy to the affected leg
• B. Keep the affected leg in a dependent position
• C. Massage the area surrounding the ulcer
• D. Encourage the client to elevate the leg for 2 hours daily

Correct answer: A

Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.

2. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

• A. Suggest moving to an assisted living facility
• B. Continue to obtain client data needed to complete the fall risk survey
• C. Reduce the frequency of fall risk assessments for this client
• D. Confirm that the client is safe living alone

Correct answer: B

Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.

3. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

4. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

5. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. Administer the medication in 2 separate injections
• B. Give the medication in the dorsal gluteal site
• C. Call to get a smaller volume ordered
• D. Check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.

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