Nursing Elites

1. A client is receiving warfarin for atrial fibrillation. Which of the following laboratory tests should the nurse expect to be ordered to monitor the effect of warfarin?

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

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). When a client is on warfarin therapy, the INR is monitored regularly to assess the anticoagulant effects of the medication. A therapeutic INR range for most indications is between 2.0 to 3.0. Choices A, C, and D are not typically used to monitor the effect of warfarin. Platelet count assesses the number of platelets in the blood, PT measures the clotting time of plasma, and PTT evaluates the intrinsic pathway of coagulation.

2. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

• A. Encourage the client to take deep breaths.
• B. Administer oxygen as needed.
• C. Teach the client pursed-lip breathing.
• D. Limit the client's fluid intake.

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

4. What is the most important assessment for a patient with respiratory distress?

• A. Monitor oxygen saturation
• B. Check for abnormal breath sounds
• C. Check for pitting edema
• D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

5. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

• A. Raise the side rails on both sides of the client's bed during repositioning.
• B. Reposition the client without assistive devices.
• C. Discuss the client's preferences to determine a repositioning schedule.
• D. Evaluate the client's ability to help with repositioning.

Correct answer: D

Rationale: The correct answer is to evaluate the client's ability to help with repositioning. When caring for a client who had a stroke, assessing their ability to participate in repositioning is crucial for promoting safety and encouraging their involvement in their care. This evaluation helps determine the level of assistance needed and supports the client's autonomy. Option A is incorrect because raising the side rails alone does not address the client's active involvement in repositioning. Option B is incorrect as using assistive devices may be necessary for safe repositioning. Option C is incorrect as discussing preferences is important but does not directly address the client's ability to assist in repositioning.

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