Nursing Elites

1. When educating a client about their new prescription for warfarin, what should the nurse advise?

• A. To have his white blood cell count tested once a month
• B. To avoid any activities that could lead to injury
• C. To avoid eating leafy green vegetables
• D. Both A and B

Correct answer: B

Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.

2. Which type of shock is related to low blood volume?

• A. Psychogenic
• B. Cardiogenic
• C. Anaphylactic
• D. Hemorrhagic

Correct answer: D

Rationale: Hemorrhagic shock, also known as hypovolemic shock, is directly related to low blood volume due to significant blood loss. In hemorrhagic shock, the body's circulating blood volume is reduced, leading to inadequate perfusion of tissues and organs. Psychogenic shock is caused by emotional distress, not blood volume changes. Cardiogenic shock results from heart failure, not low blood volume. Anaphylactic shock is due to a severe allergic reaction, not a reduction in blood volume.

3. One major difference between long term care and respite centers is the fact that long term care facilities:

• A. provide both physical and emotional care on an ongoing basis, while respite centers offer only temporary services.
• B. provide care for residents on a long-term basis, while respite centers offer only outpatient services.
• C. provide care for residents on a long-term basis, while respite centers offer only temporary services.
• D. There is no difference. Long-term care and respite care are the same.

Correct answer: C

Rationale: The major difference between long-term care and respite centers is that long-term care facilities provide both physical and emotional care on an ongoing, long-term basis. This continuous care is essential for residents who require extended assistance. In contrast, respite centers offer temporary services, providing similar care but for a short-term duration. These short-term services are designed to give family caregivers a break from their daily responsibilities. Choice A is incorrect because both long-term care and respite centers can offer both physical and emotional care, but the key distinction lies in the duration of care provided. Choice B is incorrect as respite centers do not typically offer outpatient services, and the focus is on temporary relief rather than long-term care. Choice D is incorrect as the question clearly highlights a major difference between long-term care and respite centers.

4. After change-of-shift report, which patient should the nurse assess first?

• A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
• B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
• C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
• D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

5. Surgical asepsis is being performed when:

• A. wiping down exam tables with bleach
• B. sterilizing instruments
• C. changing table paper
• D. wearing gloves when performing injections

Correct answer: B

Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.

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