Nursing Elites

1. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?

• A. International Normalized Ratio (INR)
• B. Blood glucose levels
• C. Blood pressure
• D. Temperature

Correct answer: A

Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.

2. A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?

• A. Rotate injection sites to prevent tissue damage
• B. Inject insulin into the same site to increase absorption
• C. Only use insulin pens
• D. Mix different types of insulin in the same syringe

Correct answer: C

Rationale: The correct answer is to only use insulin pens. This is because insulin pens provide a convenient and accurate way to administer insulin. Rotating injection sites is important to prevent tissue damage and promote consistent insulin absorption, making choice A incorrect. Injecting insulin into the same site can lead to lipodystrophy and is not recommended, making choice B incorrect. Mixing different types of insulin in the same syringe can alter their action profiles and is generally not recommended, making choice D incorrect.

3. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

4. Which intervention is most effective in preventing the spread of infection in a healthcare setting?

• A. Wearing gloves
• B. Using hand sanitizer
• C. Practicing hand hygiene
• D. Disinfecting surfaces

Correct answer: C

Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.

5. The client has chronic renal failure. What dietary modification is most important for this client?

• A. Increase protein intake
• B. Limit potassium-rich foods
• C. Increase sodium intake
• D. Encourage dairy products

Correct answer: B

Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.

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