Nursing Elites

1. A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?

• A. Prepare to administer warfarin.
• B. Assess characteristics of the client's pain.
• C. Monitor stools for blood and review PTT results.
• D. Continue the heparin and prepare to administer Vitamin K.

Correct answer: C

Rationale: When a client on heparin reports tarry stools, it can be indicative of gastrointestinal bleeding. The correct action for the nurse is to monitor the stools for blood and review the Partial Thromboplastin Time (PTT) results. This is essential to detect any potential bleeding complications associated with heparin therapy. Option A is incorrect because warfarin is not the immediate intervention for tarry stools in a client on heparin. Option B is irrelevant to the situation described. Option D is incorrect as Vitamin K is the antidote for warfarin, not heparin.

2. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

• A. Encourage the client to increase physical activity.
• B. Encourage the client to take rest breaks during activities.
• C. Administer a stimulant medication to reduce fatigue.
• D. Advise the client to use energy conservation techniques.

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

3. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement
• B. Encourage the client to eat potassium-rich foods
• C. Hold the next dose of furosemide
• D. Increase the client's fluid intake

Correct answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.

4. 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.

5. A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?

• A. Percussion of the abdomen.
• B. Blood glucose level.
• C. Serum electrolytes.
• D. Level of consciousness.

Correct answer: D

Rationale: The correct answer is D: Level of consciousness. When managing hepatic encephalopathy with lactulose, monitoring the client's level of consciousness is crucial as it is a key indicator of the therapeutic response to lactulose in reducing ammonia levels. Changes in consciousness can reflect the effectiveness of treatment and the progression of hepatic encephalopathy. Option A, percussion of the abdomen, is not directly related to evaluating the response to lactulose. Option B, blood glucose level, is important but not the priority in this context. Option C, serum electrolytes, while significant in liver disease, do not directly assess the impact of lactulose therapy on hepatic encephalopathy.

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