Nursing Elites

1. A client who has a new prescription for warfarin (Coumadin) is receiving discharge instructions. Which statement indicates the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should increase my intake of green leafy vegetables.
• C. I should use a soft-bristled toothbrush while taking this medication.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'I should use a soft-bristled toothbrush while taking this medication.' Using a soft-bristled toothbrush is crucial as it helps prevent bleeding gums, which is a potential side effect of warfarin therapy. Option A about taking warfarin at the same time every day is a good practice but does not directly relate to preventing side effects. Option B suggesting an increase in green leafy vegetables can interfere with warfarin's anticoagulant effects due to their vitamin K content. Option D advising to avoid alcohol is generally recommended but is not directly related to the specific side effects of warfarin.

2. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

• A. A patient who is afebrile
• B. A patient who is diaphoretic
• C. A patient with strong pedal pulses
• D. A patient with adequate skin turgor

Correct answer: B

Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.

3. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

4. The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Mild nausea
• B. Hair loss
• C. Increased fatigue
• D. Fever of 101.5°F (38.6°C)

Correct answer: D

Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.

5. A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?

• A. It decreases the risk of injecting medication into a blood vessel.
• B. It delays medication absorption.
• C. It minimizes tissue irritation.
• D. It accelerates medication excretion.

Correct answer: C

Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.

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