Nursing Elites

1. A client who has a prescription for insulin glargine is talking to a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will mix this insulin with my regular insulin before injecting it.
• B. I will store this insulin in the refrigerator after opening it.
• C. I will take this insulin twice a day.
• D. I will inject this insulin when my blood glucose is above 200 mg/dL.

Correct answer: B

Rationale: The correct answer is B because insulin glargine should be stored in the refrigerator after opening to maintain its potency. Choice A is incorrect as insulin glargine should not be mixed with other insulins. Choice C is incorrect because insulin glargine is typically taken once a day. Choice D is incorrect because insulin glargine is usually taken regardless of blood glucose levels.

2. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 92/min
• B. Serosanguineous wound drainage
• C. Yellow wound drainage
• D. Blood pressure of 118/76 mm Hg

Correct answer: C

Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.

3. A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?

• A. Serum calcium level
• B. Platelet count
• C. INR
• D. WBC count

Correct answer: C

Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.

4. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.

5. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?

• A. Cleanse the wound with povidone-iodine.
• B. Apply a hydrocolloid dressing.
• C. Perform debridement as needed.
• D. Keep the wound open to air.

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

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