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. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

3. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

• A. Bladder distention
• B. Serum albumin level
• C. Abdominal girth
• D. Breath sounds

Correct answer: D

Rationale: The correct answer is 'D. Breath sounds.' When a client receiving amlodipine develops edema, it is crucial to assess for potential heart failure, a side effect of the medication. Checking breath sounds helps in identifying any signs of pulmonary edema, a severe complication of heart failure. Choices A, B, and C are less relevant in this context. Bladder distention could be associated with urinary issues, serum albumin level with malnutrition or liver disease, and abdominal girth with gastrointestinal problems, none of which directly relate to the potential heart failure induced by amlodipine.

4. When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?

• A. Yes, I have. Do you have some questions about dying?
• B. Several times. Now, let's get your dressing changed.
• C. A few times. It was peaceful and there was no pain.
• D. Yes, but you're doing great. Are you concerned about dying?

Correct answer: A

Rationale: The correct response is to acknowledge the client's question and open the door for further discussion by asking if they have questions about dying. This approach allows the nurse to address the client's concerns and fears, promoting open communication and providing emotional support. Choices B and C do not encourage further dialogue about the client's feelings and concerns regarding death. Choice D briefly acknowledges the question but does not actively invite the client to express their thoughts and emotions regarding dying.

5. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

• A. Vastus lateralis
• B. Deltoid
• C. Ventrogluteal
• D. Dorsogluteal

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.

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