Nursing Elites

1. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory values should the nurse monitor?

• A. Prothrombin time (PT)
• B. Hemoglobin
• C. aPTT
• D. INR

Correct answer: D

Rationale: The correct answer is D, INR. The International Normalized Ratio (INR) is used to monitor the therapeutic effect of warfarin and to adjust the dose as needed. While Prothrombin time (PT) and activated Partial Thromboplastin Time (aPTT) are also related to coagulation studies, monitoring INR specifically helps in managing warfarin therapy. Hemoglobin, on the other hand, is not typically monitored in relation to warfarin therapy.

2. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

3. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

• A. Wash hands with an alcohol-based hand rub.
• B. Place the client on contact precautions.
• C. Wear a mask when entering the client's room.
• D. Double-bag all linens before removing them from the room.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

4. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

• A. Encourage the client to increase dietary fiber.
• B. Maintain the client on a low-residue diet.
• C. Provide the client with frequent high-calorie snacks.
• D. Encourage the client to eat a high-fiber diet.

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

5. A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse should identify that which of the following client reports is an indication of hypocalcemia?

• A. Constipation
• B. Frequent urination
• C. Numbness and tingling of the fingers
• D. Increased thirst

Correct answer: C

Rationale: The correct answer is C: 'Numbness and tingling of the fingers.' Post-thyroidectomy, hypocalcemia is a concern due to potential damage to the parathyroid glands that regulate calcium levels. Numbness and tingling of the fingers are classic signs of hypocalcemia. Constipation (Choice A) is not typically associated with hypocalcemia. Frequent urination (Choice B) is more indicative of conditions like diabetes or a urinary tract infection. Increased thirst (Choice D) is commonly seen in conditions such as diabetes insipidus or uncontrolled diabetes mellitus, not specifically related to hypocalcemia.

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