Nursing Elites

1. A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:

• A. Dizziness and light-headed sensations
• B. Weight gain
• C. Sensory changes in the lower extremities
• D. Fatigue

Correct answer: A

Rationale: The correct answer is 'Dizziness and light-headed sensations.' Minipress, a medication used to control hypertension, can cause hypotension as a side effect. Dizziness and light-headed sensations are common symptoms of hypotension. Weight gain, sensory changes in the lower extremities, and fatigue are not typically associated with Minipress or hypertension management. Therefore, they are incorrect choices.

2. The client with chronic pancreatitis should be taught how to monitor for which of the following possible additional problems associated with pancreatic disease?

• A. Hypertension
• B. Diabetes
• C. Hypothyroidism
• D. Graves' disease

Correct answer: B

Rationale: The correct answer is diabetes. In chronic pancreatitis, the pancreas may become unable to produce sufficient insulin, leading to diabetes. This connection underscores the importance of monitoring blood sugar levels and understanding the signs and symptoms of diabetes in clients with chronic pancreatitis. Choice A, hypertension, is not directly associated with pancreatic disease but rather with cardiovascular health. Choice C, hypothyroidism, and Choice D, Graves' disease, are unrelated to pancreatic disease and are endocrine disorders affecting the thyroid gland.

3. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:

• A. the client's hemoglobin and hematocrit are normal.
• B. red blood cells are affected first.
• C. folic acid levels are normal.
• D. the current white cell count is not affected by chemotherapy.

Correct answer: D

Rationale: Leukopenia does not present immediately after chemotherapy because time is required to clear circulating cells before the effect on precursor cell maturation in the bone marrow becomes evident. Leukopenia is characterized by an abnormally low white blood cell count. The correct answer is D because the white cell count is not immediately affected by chemotherapy. Choices A, B, and C are incorrect as they pertain to red blood cells (hemoglobin and hematocrit), which are not directly related to the delayed onset of leukopenia.

4. While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?

• A. Remove the client from the room immediately.
• B. Leave the client's room to obtain a fire extinguisher.
• C. Instruct a nurse tech to pull the fire alarm.
• D. Evacuate all clients from the unit.

Correct answer: A

Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.

5. The nurse is caring for a client receiving warfarin therapy (Coumadin�) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?

• A. Call the physician to request an increase in the Coumadin� dose.
• B. Administer a vitamin K injection IM and notify the physician of the results.
• C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin�.
• D. Notify the next shift to hold the daily dose of Coumadin� scheduled for 5:00 P.M.

Correct answer: B

Rationale: In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin� dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin� may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.

Similar Questions