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. A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?

• A. Peripheral edema
• B. Increased abdominal girth
• C. Confusion and altered mental status
• D. Yellowing of the skin

Correct answer: C

Rationale: The correct answer is C. Confusion and altered mental status are the most concerning clinical findings in a client with cirrhosis because they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Peripheral edema (choice A) and increased abdominal girth (choice B) are common manifestations of cirrhosis but are not as acutely concerning as signs of hepatic encephalopathy. Yellowing of the skin (choice D) is due to jaundice, which is already present in the client and does not directly indicate a worsening condition like confusion and altered mental status.

3. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?

• A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
• B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
• C. Push the undiluted dextrose slowly through the current IV infusion.
• D. Ask the pharmacist to add the dextrose to a TPN solution.

Correct answer: C

Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.

4. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

5. A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?

• A. Instruct the client to reduce fluid intake
• B. Monitor the client's intake and output
• C. Administer a diuretic as prescribed
• D. Assess the client for signs of fluid overload

Correct answer: D

Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.

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