Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?

• A. Avoid foods high in vitamin K, such as spinach.
• B. Report any signs of bleeding, such as bruising or nosebleeds.
• C. Take the medication on an empty stomach.
• D. Monitor for changes in blood pressure.

Correct answer: B

Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.

2. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

3. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

• A. We will call the health care provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occur.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.

4. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?

• A. Increase sodium intake to improve fluid balance
• B. Engage in regular physical activity
• C. Increase caffeine intake to improve energy
• D. Reduce potassium intake to lower blood pressure

Correct answer: B

Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.

5. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

• A. Encourage bed rest to prevent strain on the hip
• B. Assist the client with early ambulation
• C. Provide continuous passive motion therapy
• D. Administer pain medication before activity

Correct answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

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