Nursing Elites

1. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?

• A. Platelet count 150,000/mm³
• B. aPTT 30 seconds
• C. Sodium 140 mEq/L
• D. Serum creatinine 3.0 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.

2. What is the most appropriate action when a patient is experiencing confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological exam

Correct answer: A

Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.

3. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include?

• A. Establish a toileting schedule for the client.
• B. Use clothing with buttons and zippers.
• C. Discourage physical activity during the day.
• D. Engage the client in activities that increase sensory stimulation.

Correct answer: A

Rationale: The correct answer is A: Establish a toileting schedule for the client. A toileting schedule helps manage incontinence and prevent accidents, promoting client dignity. Choice B is incorrect because clothing with buttons and zippers may be difficult for a client with dementia to manage independently. Choice C is incorrect as physical activity during the day is beneficial for clients with dementia. Choice D is incorrect as activities that increase sensory stimulation may be overwhelming for a client with dementia.

4. A nurse is assessing a client who is 2 hours postoperative following a gastrectomy. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 94/min
• B. Oxygen saturation of 88%
• C. Respiratory rate of 18/min
• D. Temperature of 37.6°C (99.7°F)

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.

5. A client in active labor has ruptured membranes. What action should the nurse take?

• A. Apply a fetal heart rate monitor.
• B. Initiate fundal massage.
• C. Administer oxytocin IV.
• D. Insert an indwelling urinary catheter.

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

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