Nursing Elites

1. A nurse is planning care for a client with thrombocytopenia. Which action should be included?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving the client raw vegetables.

Correct answer: C

Rationale: The correct action to include in the care plan for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent straining during bowel movements, reducing the risk of bleeding episodes. Encouraging the client to floss daily (choice A) is important for oral hygiene but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (choice B) is more relevant for clients with neutropenia to reduce the risk of infection. Avoiding serving the client raw vegetables (choice D) is important for clients with compromised immune systems but is not specifically related to thrombocytopenia.

2. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Administer thrombolytics as prescribed.
• B. Massage the affected extremity every 2 hours.
• C. Apply warm compresses to the affected extremity.
• D. Place the client in a supine position with the legs elevated.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.

3. Which lab value is most critical to monitor in a patient receiving digoxin?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.

4. A nurse is preparing to administer a dose of digoxin to a client who has heart failure. Which of the following actions should the nurse take prior to administering the medication?

• A. Monitor the client's respiratory rate.
• B. Assess the client's apical pulse.
• C. Review the client's potassium level.
• D. Monitor the client's fluid intake.

Correct answer: B

Rationale: The correct action the nurse should take prior to administering digoxin is to assess the client's apical pulse. Digoxin is known to affect the heart rate, potentially causing bradycardia. Monitoring the client's respiratory rate (Choice A) is not directly related to administering digoxin. Reviewing the client's potassium level (Choice C) is important but not a direct prerequisite for administering digoxin. Monitoring the client's fluid intake (Choice D) is also important but not a specific action to take just before administering digoxin.

5. How should a healthcare provider respond to a patient refusing a blood transfusion for religious reasons?

• A. Respect the patient's beliefs
• B. Educate the patient on the importance of the transfusion
• C. Notify the healthcare provider
• D. Persuade the patient to accept the transfusion

Correct answer: A

Rationale: When a patient refuses a blood transfusion for religious reasons, the healthcare provider should respect the patient's beliefs. It is crucial to uphold the patient's autonomy and right to make decisions about their care, even if the provider disagrees. Educating the patient on the importance of the transfusion may be appropriate in some cases, but the initial response should always be to respect the patient's decision. Notifying the healthcare provider is not necessary as the decision lies with the patient. Persuading the patient to accept the transfusion goes against the principle of respecting the patient's autonomy and beliefs.

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