Nursing Elites

1. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?

• A. Monitor for polyuria
• B. Monitor for diaphoresis
• C. Monitor for abdominal pain
• D. Monitor for thirst

Correct answer: B

Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.

2. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

3. A nurse is providing discharge teaching to a client with a new prescription for furosemide. Which client statement indicates a need for further teaching?

• A. I will take my morning pills with food or milk.
• B. I will weigh myself every day.
• C. I will notify the nurse if I have muscle cramps.
• D. I will limit my intake of fish.

Correct answer: D

Rationale: The correct answer is D. Furosemide is a diuretic that does not require a reduction in fish consumption. Therefore, the statement 'I will limit my intake of fish' indicates a misunderstanding of dietary considerations. Choices A, B, and C are all appropriate actions related to furosemide therapy. Taking pills with food or milk can help reduce stomach upset, daily weight monitoring is crucial due to the diuretic effect of furosemide, and notifying the nurse about muscle cramps is important as it can be a sign of electrolyte imbalance, a potential side effect of furosemide.

4. A nurse is caring for a client in a mental health facility. The client’s daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

• A. I’d like to know more about what’s bothering you.
• B. Why are you feeling this way?
• C. You did the right thing by bringing him here.
• D. I’m sure your father doesn’t blame you.

Correct answer: A

Rationale: The correct response is A: 'I’d like to know more about what’s bothering you.' Encouraging the daughter to express her feelings allows her to explore her emotions, which can be helpful in addressing her guilt and providing emotional support. Choice B is not as open-ended and may come across as confrontational. Choice C may invalidate the daughter's feelings of guilt by implying she shouldn't feel that way. Choice D assumes the father's emotions and may not address the daughter's feelings of guilt effectively.

5. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client’s fluid intake to 1500 mL per day
• B. Massage the affected extremity to relieve pain
• C. Apply cold packs to the affected extremity
• D. Elevate the client’s affected extremity when in bed

Correct answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

Similar Questions