Nursing Elites

1. A client with atrial fibrillation is prescribed warfarin. What is the most important instruction the nurse should give?

• A. Take the medication with aspirin to improve effectiveness.
• B. Increase intake of green leafy vegetables to support the medication.
• C. Avoid foods high in potassium to reduce bleeding risk.
• D. Avoid alcohol and over-the-counter medications without consulting the provider.

Correct answer: D

Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.

2. A client who gave birth 48 hours ago has decided to bottle-feed the infant. The nurse observes that both breasts were swollen, warm, and tender on palpation during the assessment. Which instruction should the nurse provide?

• A. Take warm showers to reduce swelling
• B. Wear a tight-fitting bra for support
• C. Apply ice to the breasts for comfort
• D. Express milk manually to relieve discomfort

Correct answer: C

Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.

3. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

4. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.

5. Which activity is most important for a client recovering from a hip replacement to avoid during the first few weeks of recovery?

• A. Sitting in a chair for short periods
• B. Crossing the legs while sitting
• C. Walking with assistance
• D. Performing light stretching exercises

Correct answer: B

Rationale: The correct answer is B: Crossing the legs while sitting. Cross-leg position after a hip replacement can significantly increase the risk of hip dislocation. During the first few weeks of recovery, it is crucial for clients to avoid crossing their legs to protect the new joint. Choices A, C, and D are not as critical during the initial recovery phase. Sitting in a chair for short periods, walking with assistance, and performing light stretching exercises are generally encouraged activities that can help in the recovery process without posing a significant risk of complications like hip dislocation.

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