Nursing Elites

1. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

• A. Encourage warm water soaks to the right foot.
• B. Notify the case manager of the purulent drainage.
• C. Determine the patient's pulse in the right ankle.
• D. Recommend increased activity to reduce the purulent drainage.

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

2. The nurse is caring for a client receiving warfarin therapy (Coumadin�) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?

• A. Call the physician to request an increase in the Coumadin� dose.
• B. Administer a vitamin K injection IM and notify the physician of the results.
• C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin�.
• D. Notify the next shift to hold the daily dose of Coumadin� scheduled for 5:00 P.M.

Correct answer: B

Rationale: In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin� dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin� may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.

3. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

4. A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?

• A. Seizures
• B. Muscle weakness
• C. Depression
• D. Anxiety

Correct answer: B

Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.

5. When placing an IV line in a patient with active TB and HIV, which safety equipment should the nurse wear?

• A. Sterile gloves, mask, and goggles
• B. Surgical cap, gloves, mask, and proper shoewear
• C. Double gloves, gown, and mask
• D. Goggles, mask, gloves, and gown

Correct answer: D

Rationale: When dealing with a patient with active TB and HIV, the nurse should wear goggles, a mask, gloves, and a gown to protect themselves from potential exposure to infectious agents through respiratory secretions or blood. Surgical cap and proper shoewear are not specifically required for this procedure, making option B incorrect. Double gloving is not necessary in this scenario, hence option C is incorrect. Therefore, the correct choice is D as it includes all the essential protective equipment for this situation.

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