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 client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 62/min
• B. Blood pressure of 118/78 mm Hg
• C. Respiratory rate of 10/min
• D. Pain rating of 4 on a scale of 0 to 10

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.

3. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?

• A. INR 2.0
• B. Platelet count 150,000/mm3
• C. aPTT 60 seconds
• D. WBC count 8,000/mm3

Correct answer: C

Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.

4. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

5. A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?

• A. Teaching a new mother how to breastfeed.
• B. Assisting a client with ambulation post-surgery.
• C. Helping with medication administration.
• D. Delegating IV medication administration.

Correct answer: B

Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.

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