Nursing Elites

1. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

• A. Blood pressure 90/76 mm Hg.
• B. Heart rate of 85 bpm.
• C. Respiratory rate of 20 breaths/minute.
• D. Temperature of 99°F (37.2°C).

Correct answer: A

Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.

2. A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

3. A client with a history of chronic kidney disease is scheduled for a CT scan with contrast. Which laboratory value should the nurse review before the procedure?

• A. Serum potassium
• B. Blood urea nitrogen (BUN)
• C. Serum creatinine
• D. Serum glucose

Correct answer: C

Rationale: Before a CT scan with contrast, the nurse should review the serum creatinine level. This is crucial in assessing kidney function because contrast agents can potentially worsen renal function, leading to contrast-induced nephropathy. Monitoring serum creatinine helps in identifying patients at risk and taking necessary precautions. Serum potassium (Choice A) is important in conditions like hyperkalemia but is not the priority before a contrast CT scan. Blood urea nitrogen (BUN) (Choice B) is another renal function test but is not as specific as serum creatinine for assessing kidney function. Serum glucose (Choice D) is important in monitoring blood sugar levels, especially in diabetic patients, but it is not directly related to the risk of contrast-induced nephropathy in this scenario.

4. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the procedure is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.

5. The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Prothrombin time (PT)
• B. Hemoglobin level
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.

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