Nursing Elites

1. A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?

• A. Check the client's blood pressure.
• B. Assess for signs of bleeding.
• C. Assess the client's neurological status.
• D. Monitor the client's intake and output.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.

2. An older adult client with heart failure (HF) and hypertension (HTN) is receiving atenolol, furosemide, and enalapril. Which assessments are essential to evaluate the effectiveness of the medications?

• A. Bowel sounds and daily weight.
• B. Daily weight and blood pressure.
• C. Heart sounds and range of motion.
• D. Monitor for evidence of hypokalemia.

Correct answer: B

Rationale: Monitoring daily weight and blood pressure is crucial to assess the effectiveness of diuretics (furosemide) and antihypertensives (atenolol, enalapril) in managing heart failure and hypertension. Changes in weight indicate fluid status, while blood pressure readings reflect the control of hypertension. Assessing bowel sounds and range of motion are important but not directly related to evaluating the effectiveness of these specific medications in this scenario. Monitoring for hypokalemia is important due to furosemide's potential side effect, but it is not the primary assessment to evaluate medication effectiveness.

3. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

• A. Bananas
• B. Processed meats
• C. Low-fat yogurt
• D. Whole grains

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

4. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

• A. Take the medication with meals to prevent gastrointestinal upset.
• B. Report any symptoms of nausea, vomiting, or diarrhea.
• C. Monitor lithium levels regularly and maintain hydration.
• D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.

Correct answer: D

Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.

5. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?

• A. Test a stool specimen for occult blood
• B. Assist with the ambulation of a client with a chest tube
• C. Irrigate and redress a leg wound
• D. Admit a client from the emergency room

Correct answer: C

Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.

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