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 PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?

• A. Confirm that the UAP completed hand hygiene correctly
• B. Instruct the UAP to wash the hands for one minute
• C. Ask the UAP why the hands were so obviously soiled
• D. Advise the UAP to use the hand rub for 30 seconds

Correct answer: D

Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.

3. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?

• A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
• B. Assessing the color of the infant’s hands and feet
• C. Assessing the infant’s tongue
• D. Assessing the infant’s arms and legs

Correct answer: A

Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.

4. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.

5. While caring for a client with an AV fistula in the left forearm, the PN observed a palpable buzzing sensation over the fistula. What action should the PN take?

• A. Loosen the fistula dressing
• B. Report the presence of a bounding pulse
• C. Document that the fistula is intact
• D. Apply gentle pressure over the site

Correct answer: C

Rationale: A palpable buzzing sensation, known as a thrill, over an AV fistula indicates proper functioning. The correct action for the PN is to document that the fistula is intact. Choice A is incorrect because there is no need to loosen the fistula dressing when the thrill is felt. Choice B is incorrect as a bounding pulse is not related to the observed buzzing sensation. Choice D is incorrect because applying pressure is unnecessary when a thrill is present, indicating proper AV fistula function.

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