Nursing Elites

1. A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?

• A. Evaluate the client's swallowing ability.
• B. Reorient the client frequently.
• C. Patch one eye to minimize confusion.
• D. Perform range of motion exercises.

Correct answer: A

Rationale: The correct answer is to evaluate the client's swallowing ability. Osmotic demyelination can cause dysphagia, putting the client at risk for aspiration. Assessing swallowing function is crucial to prevent complications such as aspiration pneumonia. Reorienting the client frequently (Choice B) is more suitable for confusion related to conditions like delirium. Patching one eye (Choice C) is a technique used for diplopia or double vision, not specifically indicated for osmotic demyelination. Performing range of motion exercises (Choice D) may be beneficial for preventing complications of immobility but is not the priority intervention for osmotic demyelination.

2. A client with atrial fibrillation is prescribed warfarin. Which instruction should the nurse include in the teaching?

• A. Maintain a consistent intake of leafy green vegetables
• B. Use an electric razor when shaving
• C. Monitor blood pressure daily
• D. Avoid eating bananas and oranges

Correct answer: B

Rationale: Clients on warfarin are at increased risk of bleeding due to its anticoagulant effects. Using an electric razor reduces the risk of cuts and bleeding, which is an important safety precaution. While leafy greens should not be avoided, their intake should be consistent to maintain a stable level of vitamin K in the body. Monitoring blood pressure daily is important for other conditions but not directly related to warfarin therapy. Avoiding bananas and oranges is not a standard instruction for clients on warfarin.

3. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

4. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

5. While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 episodes of incontinent diarrhea
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.

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