Nursing Elites

1. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip before initiating the Coumadin
• B. Check the client’s INR before beginning Coumadin
• C. Clarify the order with the healthcare provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct answer is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip before initiating Coumadin can increase the risk of clot formation. Checking the client's INR before starting Coumadin is important but not the immediate action required. Clarifying the order with the healthcare provider is not necessary as both medications are commonly used together.

2. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

• A. Call a code immediately
• B. Assess the client for a pulse
• C. Begin chest compressions
• D. Continue to monitor the client

Correct answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

3. What are three major causes of atherosclerosis?

• A. Hyperthyroidism, underweight, and poor appetite
• B. High blood cholesterol, high blood pressure, and cigarette smoking
• C. Constipation, peptic ulcer disease, and pancreatitis
• D. Kidney failure, edema, and sodium retention

Correct answer: B

Rationale: The correct answer is B: High blood cholesterol, high blood pressure, and cigarette smoking are three major causes of atherosclerosis. Atherosclerosis is mainly attributed to the buildup of cholesterol-rich plaques in the arteries, high blood pressure causing damage to the arterial walls, and the harmful effects of cigarette smoking on blood vessels. Choices A, C, and D are incorrect because they do not directly relate to the primary causes of atherosclerosis.

4. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

• A. Instruct the client to delay intercourse until menses
• B. Schedule the client for frequent pelvic sonograms
• C. Explain that the infusion therapy will take 21 days
• D. Discuss that this may cause an ectopic pregnancy

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (choice A) is not directly related to monitoring or managing ovarian hyperstimulation. Explaining the duration of infusion therapy (choice C) is not relevant to the potential complication of ovarian hyperstimulation. Discussing the risk of ectopic pregnancy (choice D) is important but not the most appropriate intervention for managing ovarian hyperstimulation.

5. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

• A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
• B. Give two rescue breaths
• C. Look, listen, and feel for breathing
• D. Begin chest compressions

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

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