Nursing Elites

1. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

2. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?

• A. Shave the hair at the insertion site.
• B. Cleanse the site with povidone-iodine.
• C. Wear sterile gloves when changing the dressing.
• D. Change the IV site every 48 to 72 hours.

Correct answer: D

Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.

3. A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Empty the drainage collection chamber when it is half full.
• C. Keep the drainage system below the level of the client's chest.
• D. Strip the chest tube every 2 hours to maintain patency.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client with a chest tube is to keep the drainage system below the level of the client's chest. This positioning helps prevent fluid from flowing back into the pleural space, ensuring proper drainage and effective functioning of the chest tube. Clamping the chest tube intermittently or stripping it frequently can lead to complications and should be avoided. Emptying the drainage collection chamber at specific intervals may vary based on institutional protocols, but it should be done when it is no more than two-thirds full to prevent backflow and maintain accurate monitoring of drainage output.

4. A nurse is caring 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 medication?

• A. Hemoglobin
• B. Platelet count
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: D

Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.

5. A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which result is reportable?

• A. Herpes simplex
• B. Human papillomavirus
• C. Candidiasis
• D. Chlamydia

Correct answer: D

Rationale: Chlamydia is a reportable sexually transmitted infection. Reporting cases of Chlamydia to the health department is crucial for disease surveillance, contact tracing, and implementing public health interventions. Herpes simplex, human papillomavirus, and candidiasis are not typically reportable infections, as they do not pose the same public health risks as Chlamydia.

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