Nursing Elites

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Prothrombin time (PT)
• B. Hemoglobin level
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

2. The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?

• A. Pupils reactive to accommodation.
• B. Nystagmus present with pupillary focus.
• C. Peripheral vision intact.
• D. Consensual pupillary constriction present.

Correct answer: A

Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.

3. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

4. A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Encourage fluid intake to thin secretions.
• B. Administer a mucolytic agent.
• C. Increase humidity in the client's room.
• D. Perform deep suctioning as needed.

Correct answer: C

Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.

5. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle-feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.

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