Nursing Elites

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.

2. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

3. A client with diabetes mellitus reports feeling anxious, shaky, and weak. These findings are manifestations of which of the following complications?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Ketoacidosis
• D. Dawn phenomenon

Correct answer: B

Rationale: The correct answer is B, Hypoglycemia. In diabetes mellitus, hypoglycemia can lead to symptoms such as anxiety, shakiness, and weakness due to low blood sugar levels. Hyperglycemia (choice A) is high blood sugar levels and typically presents with symptoms like increased thirst and frequent urination. Ketoacidosis (choice C) is a serious complication of diabetes characterized by high levels of ketones in the blood, leading to symptoms such as fruity breath and rapid breathing. The Dawn phenomenon (choice D) refers to an abnormal early-morning increase in blood sugar levels without an associated hypoglycemia during the night.

4. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

5. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement?

• A. Give an around-the-clock schedule for administration of analgesics.
• B. Administer analgesic medication as needed when the pain is severe.
• C. Provide medication to keep the client sedated and unaware of stimuli.
• D. Offer a medication-free period to allow the client to engage in daily activities.

Correct answer: A

Rationale: The correct action for the LPN/LVN to implement is to give an around-the-clock schedule for administration of analgesics. This approach helps maintain consistent pain management by providing the medication regularly, preventing the pain from becoming severe. Choice B is incorrect because waiting for severe pain before administering the analgesic may lead to uncontrolled pain levels. Choice C is inappropriate as the goal of pain management in hospice care is to provide comfort without unnecessary sedation. Choice D is also incorrect as offering a medication-free period may result in inadequate pain control for the client.

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