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 reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

• A. Serum glucose level.
• B. Serum calcium level.
• C. Lymphocyte count.
• D. Serum potassium level.

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, elevated cortisol levels lead to increased gluconeogenesis, insulin resistance, and breakdown of proteins and fats, resulting in elevated blood glucose levels. This is known as hyperglycemia. The other options, including serum calcium level (choice B), lymphocyte count (choice C), and serum potassium level (choice D), are not typically affected by Cushing's disease. Therefore, they are incorrect choices.

3. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

• A. Administer the injection into the muscle of your thigh.
• B. Pinch the skin before inserting the needle.
• C. Rub the injection site after administering the medication.
• D. Administer the injection into the fat tissue of your abdomen.

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

4. What is the first action for a healthcare provider when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.

5. What is the best position for a patient experiencing shortness of breath?

• A. Supine position
• B. Semi-Fowler's position
• C. Trendelenburg position
• D. Prone position

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.

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