Nursing Elites

1. A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?

• A. Serum calcium level
• B. Platelet count
• C. INR
• D. WBC count

Correct answer: C

Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.

2. A client receiving chemotherapy is being taught about infection prevention by a nurse. Which of the following instructions should the nurse include?

• A. Wear a mask when gardening.
• B. Avoid crowds to reduce the risk of infection.
• C. You should take a daily vitamin to prevent infection.
• D. Increase your intake of high-protein foods.

Correct answer: B

Rationale: The correct answer is B: 'Avoid crowds to reduce the risk of infection.' Clients receiving chemotherapy are immunocompromised, so avoiding crowds can help decrease the likelihood of exposure to infections. Wearing a mask when gardening (choice A) is important but not directly related to infection prevention in the context of chemotherapy. Taking a daily vitamin (choice C) may be beneficial for overall health but is not specifically focused on infection prevention. Increasing intake of high-protein foods (choice D) is essential for nutrition but does not directly address infection prevention.

3. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a bedtime snack if my blood sugar is below 200 mg/dL.
• B. I will eat more sugar-free candy to help control my blood sugar.
• C. I will check my blood sugar every morning before breakfast.
• D. I will avoid physical activity if my blood sugar is below 100 mg/dL.

Correct answer: C

Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.

4. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

5. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?

• A. Encourage the client to take deep breaths.
• B. Place the client in a high-Fowler's position.
• C. Administer a bronchodilator.
• D. Administer oxygen at 6 L/min via face mask.

Correct answer: B

Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.

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