Nursing Elites

1. A nurse is caring for a client with deep vein thrombosis who is prescribed warfarin. Which of the following client statements indicates a need for further teaching?

• A. I will avoid vitamin K-rich foods.
• B. I will avoid using aspirin while on this medication.
• C. I will monitor my blood pressure regularly.
• D. I will increase my intake of leafy greens.

Correct answer: D

Rationale: The correct answer is D. Warfarin's effectiveness is reduced by high intake of vitamin K-rich foods, so increasing their intake would contradict the treatment plan. Choices A, B, and C are all appropriate statements for a client on warfarin therapy. Avoiding vitamin K-rich foods helps maintain the medication's effectiveness, avoiding aspirin reduces the risk of bleeding, and monitoring blood pressure is essential for overall health monitoring.

2. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

3. A healthcare professional is assessing a client who is receiving opioid analgesics. Which of the following findings should the professional report to the provider?

• A. Oxygen saturation of 94%
• B. Blood pressure of 110/70 mm Hg
• C. Respiratory rate of 12/min
• D. Heart rate of 88/min

Correct answer: C

Rationale: A respiratory rate of 12/min may indicate respiratory depression, a potential side effect of opioid analgesics. Respiratory depression can be a serious complication that requires immediate intervention. Monitoring the respiratory rate is crucial in clients receiving opioids to prevent adverse events. Oxygen saturation, blood pressure, and heart rate are important parameters to assess, but a low respiratory rate is a more critical finding that warrants immediate reporting to the healthcare provider.

4. A client who is at 36 weeks of gestation is scheduled for a nonstress test. Which of the following client statements indicates an understanding of the teaching?

• A. I should fast for 12 hours before the test.
• B. I should expect the test to take about 10 minutes.
• C. I should have a full bladder for this test.
• D. I will need to have my blood glucose checked before the test.

Correct answer: B

Rationale: The correct answer is B. The nonstress test takes about 10 minutes and evaluates fetal heart rate in response to fetal movement. Choice A is incorrect because fasting is not required for a nonstress test. Choice C is incorrect as a full bladder is not necessary for this test. Choice D is incorrect as blood glucose checking is not typically part of a nonstress test.

5. Which electrolyte imbalance is commonly associated with furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, commonly causes the loss of potassium in the urine, leading to hypokalemia. This electrolyte imbalance can result in various complications such as cardiac arrhythmias and muscle weakness. Choice B, Hyponatremia, is not typically associated with furosemide use. Choice C, Hyperkalemia, is the opposite of the expected electrolyte imbalance caused by furosemide. Choice D, Hypercalcemia, is not a common side effect of furosemide.

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