Nursing Elites

1. During an integumentary assessment for a group of clients, a healthcare professional notes various skin findings. Which of the following findings should the professional recognize as requiring immediate intervention?

• A. Pallor
• B. Cyanosis
• C. Jaundice
• D. Erythema

Correct answer: B

Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.

2. A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?

• A. Exercise 1 hour before bedtime.
• B. Eat a light carbohydrate snack before bedtime.
• C. Drink a cup of hot cocoa before bedtime.
• D. Take a 30-minute nap daily.

Correct answer: B

Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.

3. During a client admission, how should the nurse conduct medication reconciliation?

• A. Compare the client’s home medications to the provider's prescriptions.
• B. Review the client’s medical history.
• C. Assess the client's current medications.
• D. Ask the client about their allergies.

Correct answer: A

Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.

4. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

• A. Ask another nurse to observe the medication wastage
• B. Notify the pharmacy when wasting the medication
• C. Lock the remaining medication in the controlled substance cabinet
• D. Dispose of the vial with the remaining medication in a sharps container

Correct answer: A

Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.

5. The client is receiving discharge instructions for warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will have my blood tested regularly to monitor my INR levels.
• C. I will take the medication at the same time every day.
• D. I will use a soft toothbrush to prevent bleeding gums.

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin need to be consistent with their vitamin K intake to maintain a balance in blood clotting. Avoiding foods high in vitamin K is essential as they can interfere with the medication's effectiveness. Choices B, C, and D are all correct statements regarding warfarin therapy. Regular blood testing to monitor INR levels ensures the medication is working effectively, taking the medication at the same time daily maintains a consistent level in the bloodstream, and using a soft toothbrush helps prevent gum bleeding due to warfarin's anticoagulant effects.

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