Nursing Elites

1. What is the primary reason for applying sequential compression devices (SCDs) to a patient’s legs postoperatively?

• A. To prevent deep vein thrombosis (DVT)
• B. To promote wound healing
• C. To reduce postoperative pain
• D. To maintain body temperature

Correct answer: A

Rationale: The correct answer is A: To prevent deep vein thrombosis (DVT). Sequential compression devices (SCDs) are used postoperatively to prevent DVT by promoting blood circulation in the legs. This helps reduce the risk of blood clots forming in the deep veins of the legs. Choice B, to promote wound healing, is incorrect as SCDs are primarily used for circulatory purposes rather than wound healing. Choice C, to reduce postoperative pain, is incorrect as the primary purpose of SCDs is not pain management but rather prevention of DVT. Choice D, to maintain body temperature, is incorrect as SCDs are not designed for regulating body temperature but for preventing circulatory issues.

2. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?

• A. How much exercise did the child have today?
• B. Did the child perform a finger stick?
• C. When did the child last urinate?
• D. Has the child eaten recently?

Correct answer: B

Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.

3. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

4. A post-operative client is prescribed sequential compression devices (SCDs) while on bed rest. What is the primary purpose of this device?

• A. To prevent deep vein thrombosis (DVT).
• B. To improve circulation in the legs.
• C. To prevent pressure ulcers.
• D. To alleviate post-operative pain.

Correct answer: A

Rationale: The correct answer is A: 'To prevent deep vein thrombosis (DVT).' Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs and reducing venous stasis, which is a common risk for post-operative clients who are on bed rest. While SCDs do improve circulation in the legs indirectly, their primary purpose is DVT prevention. Preventing pressure ulcers is typically achieved through repositioning and support surfaces, not with SCDs, making choice C incorrect. SCDs are not used to alleviate post-operative pain, so choice D is also incorrect.

5. The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?

• A. Report the findings to the charge nurse
• B. Monitor the client's temperature hourly
• C. Offer the client fluids frequently
• D. Provide care to moisten oral mucosa

Correct answer: A

Rationale: The change in the client’s condition, especially confusion and a new cough, may indicate the onset of an infection such as pneumonia, which requires immediate attention. Reporting to the charge nurse ensures prompt evaluation and intervention. Monitoring the client's temperature hourly (Choice B) could be important but not the most critical at this point. Offering the client fluids frequently (Choice C) and providing care to moisten oral mucosa (Choice D) are not the priority interventions when facing potential signs of infection and confusion in the client.

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