Nursing Elites

1. A nurse is reviewing the medical record of a client who is receiving warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider?

• A. International normalized ratio (INR) of 2.5
• B. Platelet count of 180,000/mm³
• C. Prothrombin time (PT) of 12 seconds
• D. Partial thromboplastin time (PTT) of 30 seconds

Correct answer: C

Rationale: A prothrombin time (PT) of 12 seconds is below the therapeutic range for warfarin and indicates a need for dosage adjustment. The correct answer is C. A normal International normalized ratio (INR) for a client on warfarin therapy is usually between 2.0 to 3.0; therefore, an INR of 2.5 is within the expected range. A platelet count of 180,000/mm³ is within the normal range (150,000 to 450,000/mm³) and does not require immediate reporting. A partial thromboplastin time (PTT) of 30 seconds is also within the normal range (25-35 seconds) and does not indicate a need for urgent action.

2. A client post-lumbar puncture should be in which position?

• A. High Fowler's position
• B. Prone position
• C. Supine position
• D. Sitting position

Correct answer: C

Rationale: The most appropriate position for a client post-lumbar puncture is the supine position. Placing the client in a supine position helps prevent spinal headaches by allowing the puncture site to seal effectively and reducing the risk of cerebrospinal fluid leakage. High Fowler's position, prone position, and sitting position are not recommended after a lumbar puncture as they may increase the risk of complications like spinal headaches.

3. What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?

• A. Edema, weight gain, shortness of breath
• B. Fever, cough, chest pain
• C. Increased heart rate, low blood pressure
• D. Increased blood pressure, jugular venous distention

Correct answer: A

Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.

4. A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile. Which of the following information should the nurse include in the teaching?

• A. Assign the client to a room with a negative air-flow system
• B. Use alcohol-based hand sanitizer when leaving the client's room
• C. Clean contaminated surfaces in the client's room with a phenol solution
• D. Have family members wear a gown and gloves when visiting

Correct answer: D

Rationale: The correct answer is D because having family members wear a gown and gloves when visiting clients with C. difficile is crucial to prevent the transmission of the infection. Options A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning contaminated surfaces with a phenol solution are not specific measures for preventing the spread of C. difficile.

5. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?

• A. Administer an antiemetic
• B. Irrigate the NG tube with sterile water
• C. Increase the suction setting
• D. Replace the NG tube

Correct answer: B

Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.

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