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 who is 1 day postpartum plans to breastfeed. Which statement indicates an understanding of the teaching provided by the nurse?

• A. I will breastfeed every 4 hours.
• B. I will feed my baby from each breast for 5 minutes.
• C. I will use both breasts at each feeding.
• D. I will pump my breasts if my baby does not wake up to feed.

Correct answer: C

Rationale: The correct answer is C. Using both breasts at each feeding helps ensure adequate milk production and consumption. Option A is incorrect because breastfeeding should be done on demand rather than following a strict schedule. Option B is incorrect as limiting feeding time to 5 minutes per breast may not provide the baby with enough milk. Option D is also incorrect as pumping should not replace direct breastfeeding unless there is a specific medical reason to do so.

3. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

4. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following actions should the nurse take?

• A. Administer naloxone
• B. Administer diazepam
• C. Encourage oral fluid intake
• D. Administer magnesium sulfate

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with alcohol use disorder experiencing withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to manage withdrawal symptoms in these clients by reducing anxiety, tremors, and the risk of seizures. Administering naloxone (Choice A) is used for opioid overdose, not alcohol withdrawal. Encouraging oral fluid intake (Choice C) is generally beneficial but not a specific intervention for alcohol withdrawal. Administering magnesium sulfate (Choice D) is not indicated for alcohol withdrawal but may be used for other conditions like preeclampsia or eclampsia.

5. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

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