Nursing Elites

1. Which assessment finding is expected with myxedema?

• A. Increased pulse rate
• B. Decreased temperature
• C. Fine tremors
• D. Weight loss

Correct answer: B

Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.

2. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

• A. Maintain two points of support on the ground at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

3. A nurse is providing discharge instructions to a client with home oxygen therapy. What safety measure should the nurse emphasize?

• A. Allow smoking in designated outdoor areas
• B. Keep oxygen tanks upright and away from heat sources
• C. Store oxygen tanks in a closet when not in use
• D. Keep oxygen equipment at least 10 feet away from open flames

Correct answer: B

Rationale: The correct safety measure that the nurse should emphasize is to keep oxygen tanks upright and away from heat sources. This is crucial to prevent the risk of fire or explosion. Choice A is incorrect as smoking near oxygen can lead to a fire hazard. Choice C is also incorrect as storing oxygen tanks in enclosed spaces can be dangerous. Choice D, although related to safety, does not address the immediate risk of keeping oxygen tanks away from heat sources.

4. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

• A. Apply a cold compress
• B. Notify the physician immediately
• C. Apply a warm compress
• D. Administer anti-inflammatory medication

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

5. What are the nursing considerations for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Educate patient on dietary restrictions
• C. Ensure adequate hydration and nutrition
• D. Ensure that the patient remains immobile

Correct answer: A

Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.

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