Nursing Elites

1. A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn?

• A. The client’s belief that his needs will be met through education
• B. The nurse’s empathy regarding the client's self-injection
• C. The client seeking family approval by agreeing to a teaching plan
• D. The nurse explaining the need for education to the client

Correct answer: A

Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.

2. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

3. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

• A. Breath sounds
• B. Client’s history of smoking
• C. Current medication list
• D. Client’s family history of respiratory illness

Correct answer: A

Rationale: In a client with pneumonia, assessing breath sounds is crucial as it provides immediate information about the client's respiratory status. Changes in breath sounds could indicate complications like fluid accumulation or worsening pneumonia. While the client's history of smoking (Choice B), current medication list (Choice C), and family history of respiratory illness (Choice D) are important factors to consider, they are not as urgent or directly related to the client's immediate condition as assessing breath sounds.

4. When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?

• A. Insert the catheter at a 45° angle
• B. Place the client's arm in a dependent position
• C. Shave excess hair from the insertion site
• D. Initiate IV therapy in the veins of the hand

Correct answer: B

Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.

5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

• A. Bleeding time
• B. Coagulation time
• C. Prothrombin time
• D. Partial thromboplastin time

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.

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