Nursing Elites

1. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?

• A. Administer it intramuscularly
• B. Monitor APTT levels
• C. Give it in the abdomen
• D. Administer rapidly

Correct answer: C

Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.

2. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

3. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?

• A. Measure the client’s abdominal girth daily
• B. Monitor the client’s hemoglobin level
• C. Administer lactulose as prescribed
• D. Weigh the client weekly

Correct answer: A

Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.

4. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?

• A. A 6-year-old with a dislocated shoulder
• B. A 26-year-old with sickle cell disease and severe joint pain
• C. A 76-year-old with confusion, fever, and foul-smelling urine
• D. A 50-year-old with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.

5. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?

• A. Take the medication on an empty stomach
• B. Notify your provider if your stool becomes dark green
• C. Decrease dietary fiber intake while taking this medication
• D. Take prescribed antacids at the same time as this medication

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate for anemia is to take the medication on an empty stomach. This is because ferrous sulfate is best absorbed in an acidic environment, which is enhanced on an empty stomach. However, if the client experiences gastrointestinal side effects, they can take the medication with food. Choice B, notifying the provider if stool becomes dark green, is correct because dark or black stools are common with iron therapy and not a cause for concern. Choice C, decreasing dietary fiber intake, is incorrect as dietary fiber does not interfere with the absorption of ferrous sulfate. Choice D, taking prescribed antacids at the same time, is incorrect as antacids can decrease the absorption of ferrous sulfate.

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