Nursing Elites

1. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?

• A. Monitor the client for bradycardia.
• B. Check the client’s blood pressure for signs of hypotension.
• C. Monitor the client for signs of hyperglycemia.
• D. Monitor for signs of fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.

2. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

• A. Administer a dose of vitamin K to reverse the effects of warfarin.
• B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
• C. Increase the client’s warfarin dosage to prevent clot formation.
• D. Notify the healthcare provider immediately and hold the next dose of warfarin.

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

3. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

4. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

5. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?

• A. Administer diuretics as prescribed.
• B. Prepare the client for dialysis.
• C. Restrict the client’s fluid intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.

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