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. When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?

• A. Place sterile items around the sterile field
• B. Keep hands below waist level to avoid contamination
• C. Open the sterile package away from the body
• D. Avoid reaching over the sterile field

Correct answer: D

Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.

3. What is the most common sign of a localized infection?

• A. Fever
• B. Elevated white blood cell count
• C. Redness, warmth, and swelling at the site of infection
• D. Chills and shivering

Correct answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.

4. Which of the following is an appropriate intervention for a patient experiencing a hypertensive crisis?

• A. Placing the patient in a supine position
• B. Administering a beta-blocker intravenously
• C. Encouraging the patient to drink fluids
• D. Applying a cold compress to the forehead

Correct answer: B

Rationale: Administering a beta-blocker intravenously is the correct intervention for a patient experiencing a hypertensive crisis. Beta-blockers help quickly reduce blood pressure and prevent complications such as stroke or heart attack. Placing the patient in a supine position can worsen the condition by reducing venous return and increasing the workload of the heart. Encouraging the patient to drink fluids is not recommended as it can exacerbate hypertension by increasing fluid volume. Applying a cold compress to the forehead does not address the underlying cause of the hypertensive crisis and is unlikely to provide significant benefit.

5. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

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