Nursing Elites

1. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

• A. Providing a high-protein snack
• B. Assisting the child to reposition
• C. Placing weights on the child’s bed
• D. Massaging pressure points

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

2. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?

• A. Swelling in the limb
• B. Decreased heart rate
• C. Increased appetite
• D. Improved mobility

Correct answer: A

Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.

3. A nurse is caring for a client who is receiving IV diltiazem for atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem can cause further lowering of blood pressure, so it should not be administered if the client is already hypotensive. Monitoring blood pressure is crucial before giving diltiazem. Choice B, tachycardia, is not a contraindication for diltiazem use; in fact, diltiazem is used to slow down the heart rate. Choice C, decreased level of consciousness, may indicate other issues but is not a direct contraindication for diltiazem. Choice D, history of diuretic use, is not a contraindication by itself; however, caution should be exercised when diltiazem is given with diuretics due to potential interactions.

4. A client is being taught about the use of metformin. Which of the following should be included?

• A. It is taken with food
• B. It can cause hyperglycemia
• C. It should be taken once daily
• D. It is an injectable medication

Correct answer: A

Rationale: Corrected Rationale: Metformin should be taken with food to minimize gastrointestinal side effects. Choice A is the correct answer as taking metformin with meals can help reduce the likelihood of experiencing gastrointestinal side effects like diarrhea and nausea, which are common side effects of metformin. Choice B is incorrect because metformin actually helps lower blood sugar levels and does not cause hyperglycemia. Choice C is incorrect as metformin is usually taken twice or even three times a day, not just once daily. Choice D is incorrect because metformin is an oral medication, not an injectable one.

5. A nurse is caring for a client receiving anticoagulation therapy. Which of the following should the nurse monitor?

• A. INR levels
• B. Blood glucose
• C. Serum creatinine
• D. Liver function

Correct answer: A

Rationale: Corrected Rationale: When caring for a client receiving anticoagulation therapy, the nurse should monitor the INR levels. INR (International Normalized Ratio) reflects the blood's ability to clot properly. It is crucial to monitor INR levels to ensure the anticoagulation therapy is within the therapeutic range and to prevent bleeding complications. Monitoring blood glucose levels (Choice B) is more relevant for clients with diabetes or those on medications affecting blood sugar. Serum creatinine (Choice C) is typically monitored to assess kidney function. Liver function (Choice D) is assessed through tests like AST, ALT, and bilirubin levels, and it is more relevant for assessing liver health rather than monitoring anticoagulation therapy.

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