Nursing Elites

1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?

• A. International normalized ratio (INR) of 1.0.
• B. Prothrombin time (PT) of 12 seconds.
• C. Partial thromboplastin time (PTT) of 60 seconds.
• D. International normalized ratio (INR) of 2.5.

Correct answer: D

Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.

2. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

3. A client with a history of hypertension is prescribed enalapril (Vasotec). Which statement by the client indicates a need for further teaching?

• A. I will monitor my blood pressure regularly.
• B. I will report any signs of infection to my healthcare provider.
• C. I will avoid using salt substitutes.
• D. I will increase my intake of potassium-rich foods.

Correct answer: D

Rationale: The correct answer is D. Increasing potassium intake can lead to hyperkalemia, especially in clients taking ACE inhibitors like enalapril. Hyperkalemia is a potential side effect of ACE inhibitors and can be exacerbated by consuming potassium-rich foods. Monitoring blood pressure regularly (A) is important when taking antihypertensive medications. Reporting signs of infection (B) is crucial as ACE inhibitors can lower the immune response. Avoiding salt substitutes (C) is necessary because they may contain potassium chloride, leading to increased potassium levels, which can be harmful in combination with ACE inhibitors.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?

• A. The client is able to expectorate secretions easily.
• B. The client's oxygen saturation is 92%.
• C. The client's respiratory rate is 20 breaths per minute.
• D. The client's arterial blood gases show a pH of 7.35.

Correct answer: C

Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.

5. The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?

• A. Hyperpigmentation of the skin.
• B. Low blood pressure.
• C. Nausea and vomiting.
• D. Hypoglycemia.

Correct answer: B

Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.

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