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 supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nursing assistant aspirates and measures the amount of the gastric aspirate
• B. The nursing assistant elevates the head of the client’s bed 30 degrees
• C. The nursing assistant warms the formula to room temperature
• D. B, C

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

3. In supply and equipment management, what is the FIRST step in the procurement process?

• A. Keep hand receipts up to date
• B. Establish requirements
• C. Requisition supplies and equipment through the proper channels
• D. Properly receive, inspect, and store required items

Correct answer: B

Rationale: The correct answer is B: Establish requirements. In the procurement process, the initial step involves determining and establishing the requirements for the supplies and equipment needed. This step is crucial as it sets the foundation for the entire procurement process by outlining the specific needs and specifications. Choice A, 'Keep hand receipts up to date,' is not the first step but rather a later administrative task. Choice C, 'Requisition supplies and equipment through the proper channels,' comes after establishing requirements. Choice D, 'Properly receive, inspect, and store required items,' is the final step in the procurement process, focusing on the physical receipt and handling of the procured items.

4. Which medication should a patient with a history of peptic ulcer disease avoid?

• A. Acetaminophen
• B. Antacids
• C. Nonsteroidal anti-inflammatory drugs
• D. Antihistamines

Correct answer: C

Rationale: Patients with a history of peptic ulcer disease should avoid Nonsteroidal anti-inflammatory drugs (NSAIDs) because they can worsen peptic ulcers due to their effects on the stomach lining. Acetaminophen (Choice A) is a safer alternative for pain relief in such patients as it does not have the same ulcerogenic effects. Antacids (Choice B) can actually help alleviate symptoms by neutralizing stomach acid and are generally safe to use. Antihistamines (Choice D) are not known to exacerbate peptic ulcers and can be used safely for conditions like allergies.

5. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

• A. 32-year-old with diarrhea for 6 hours
• B. 2-year-old with 1 wet diaper in 24 hours
• C. 40-year-old with abdominal cramping
• D. 10-year-old who is nauseated

Correct answer: B

Rationale: In cases of food poisoning, a 2-year-old with reduced urine output is a critical finding indicating dehydration, requiring immediate attention to prevent complications. The reduced urine output is a sign of decreased fluid intake or increased fluid loss, putting the child at high risk for dehydration. This client should be seen first to assess hydration status, initiate necessary interventions, and prevent further complications. While the other symptoms presented by the other clients are concerning, the 2-year-old's decreased urine output poses the most immediate threat to their well-being.

Similar Questions