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. A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?

• A. Take one puff every 5 minutes until symptoms improve.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Shake the inhaler for 2 seconds before use.
• D. Exhale forcefully after each puff.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.

3. What is the priority intervention for a patient with dehydration?

• A. Administer IV fluids
• B. Monitor intake and output
• C. Administer oral fluids
• D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

4. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?

• A. Pregabalin
• B. Lorazepam
• C. Colchicine
• D. Codeine

Correct answer: A

Rationale: The correct answer is A: Pregabalin. Pregabalin is a first-line medication for treating pain in clients with fibromyalgia. It works by decreasing the number of pain signals sent out by damaged nerves. Choice B, Lorazepam, is a benzodiazepine used for anxiety and not indicated for fibromyalgia pain. Choice C, Colchicine, is used to treat gout by reducing inflammation and not indicated for fibromyalgia. Choice D, Codeine, is an opioid analgesic that is not typically recommended for fibromyalgia due to concerns about tolerance and dependence.

5. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the tube with 30 mL of water every 4 hours.
• B. Position the client on the left side during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Check gastric residual every 2 hours.

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

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