Nursing Elites

1. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

• A. Dorsiflexes the right foot and left on command
• B. A 3 by 5 cm ecchymosis area covering the right calf
• C. Right calf is 3 cm larger in circumference than the left
• D. Bilateral lower extremity has 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

2. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

3. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

• A. Pink lips and tongue with cyanotic hands and feet
• B. Respiration rate of 40 and heart rate of 144
• C. Centralized cyanosis and tachycardia when crying
• D. Desquamation from areas of cracked, parchment-like skin

Correct answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

4. A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?

• A. Refer the client to a healthcare provider for a pelvic examination
• B. Notify the parents that the client needs to be picked up from school
• C. Determine the date of the client's last menstrual period
• D. Ask the client to lie down for a pelvic examination

Correct answer: A

Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.

5. A 7-year-old with cystic fibrosis (CF) has received instructions about home care. Which statement made by the child's mother indicates that further teaching is needed?

• A. My child should not have a cough at all times
• B. He needs to take pancreatic enzymes with meals and snacks
• C. He needs to use a bronchodilator every day
• D. His dietary intake needs to be high in protein and calories

Correct answer: A

Rationale: The correct answer is A. A cough at all times is not normal in a child with cystic fibrosis (CF) and indicates the need for further teaching on CF management. Choices B, C, and D are correct statements in managing CF: taking pancreatic enzymes with meals and snacks, using a bronchodilator daily, and maintaining a high-protein and high-calorie dietary intake are all appropriate for a child with CF.

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