Nursing Elites

1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the LPN/LVN monitor closely while the client is taking this medication?

• A. Blood glucose level
• B. Prothrombin time (PT) and INR
• C. Serum potassium level
• D. Serum creatinine level

Correct answer: B

Rationale: The LPN/LVN should closely monitor Prothrombin time (PT) and INR (Choice B) levels in a client receiving warfarin. These values are crucial to ensure the medication's effectiveness and prevent complications like bleeding. Monitoring blood glucose level (Choice A) is not directly relevant to warfarin therapy. While serum potassium level (Choice C) and serum creatinine level (Choice D) are important for other conditions or medications, they are not specifically required to be monitored when a client is on warfarin.

2. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm
• B. Extinguish the fire
• C. Evacuate the client
• D. Confine the fire

Correct answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

3. Which toy is most appropriate for an 18-month-old child?

• A. A pull toy
• B. A puzzle with large pieces
• C. A book with large pictures
• D. A doll with small clothes

Correct answer: A

Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.

4. A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?

• A. Place the shallow end of the fracture pan under the client’s buttocks.
• B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
• C. Keep the bed flat while the client is on the fracture pan.
• D. Hyperextend the client’s back while the fracture pan is in place.

Correct answer: A

Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.

5. A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

• A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
• B. “It’s been so stressful for me to have to depend on my child to help around the house.”
• C. “I just heard my friend Al die. That’s the third one in 3 months.”
• D. “I keep forgetting which medications I have taken during the day.”

Correct answer: C

Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.

Similar Questions