Nursing Elites

1. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin K.
• B. Increase intake of dairy products.
• C. Limit intake of citrus fruits.
• D. Avoid high-sodium foods.

Correct answer: A

Rationale: Patients on warfarin should avoid foods high in vitamin K because vitamin K can interfere with the anticoagulant effect of the medication. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods may decrease the effectiveness of the medication. Choices B, C, and D are incorrect. Increasing intake of dairy products, limiting citrus fruits, or avoiding high-sodium foods are not directly related to the mechanism of action of warfarin or its dietary considerations.

2. What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?

• A. Administer an antiemetic before starting the chemotherapy.
• B. Instruct the client to drink plenty of fluids during the treatment.
• C. Keep the head of the bed elevated until the treatment is completed.
• D. Monitor the client's intravenous site hourly during the treatment.

Correct answer: D

Rationale: Monitoring the intravenous site hourly is essential to identify early signs of extravasation, such as swelling or pain, which can help prevent tissue damage. Prompt detection allows for immediate intervention, minimizing the risk of serious complications associated with vesicant extravasation.

3. A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?

• A. Reports reduced nasal discharge.
• B. Denies having coughing spells.
• C. Able to sleep through the night.
• D. Expectorating bronchial secretions.

Correct answer: B

Rationale: The correct answer is B. Denying having coughing spells indicates the effectiveness of benzonatate, an antitussive that suppresses coughing. The goal of antitussive medications like benzonatate is to reduce or eliminate coughing, so the absence of coughing spells signifies the drug's efficacy. The other options do not directly reflect the medication's intended effect and are not specific indicators of benzonatate's effectiveness.

4. The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?

• A. Hypertension and hyperglycemia.
• B. Hyperpigmentation and hypotension.
• C. Exophthalmos and tachycardia.
• D. Weight gain and fluid retention.

Correct answer: B

Rationale: Hyperpigmentation and hypotension are classic clinical manifestations of Addison's disease due to decreased cortisol production. Hyperpigmentation occurs due to elevated levels of ACTH, leading to increased melanin synthesis. Hypotension results from aldosterone deficiency, causing sodium loss and volume depletion.

5. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?

• A. Delirium
• B. Presbyopia
• C. Presbycusis
• D. Cerebral dysfunction

Correct answer: C

Rationale: The correct answer is C, Presbycusis. Presbycusis is age-related hearing loss that often affects the ability to hear high-pitched sounds, making speech appear mumbled. This condition is common in older adults and can lead to difficulties in understanding conversations, as in the case of the client complaining about people whispering and mumbling.

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