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. The nurse is caring for a client with pericarditis. Which of the following nursing interventions will promote comfort for the client?

• A. Auscultating the client's heart sounds
• B. Provide the client with a diversionary activity
• C. Encourage deep breathing
• D. Maintain a patent intravenous access

Correct answer: B

Rationale: Providing a diversionary activity is the most appropriate nursing intervention to promote comfort for a client with pericarditis. This intervention helps to distract the patient and reduce discomfort by focusing their attention elsewhere. Auscultating heart sounds, while important for monitoring the condition, does not directly address the client's comfort. Encouraging deep breathing can be beneficial for some conditions but may not be specifically aimed at promoting comfort in pericarditis. Maintaining a patent intravenous access is essential for treatment access and management of the condition, but it does not directly promote comfort for the client.

3. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

4. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?

• A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
• B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
• C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
• D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute

Correct answer: D

Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.

5. Which electrolyte imbalance is most commonly associated with seizures?

• A. Hyponatremia
• B. Hypercalcemia
• C. Hyperkalemia
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

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