Nursing Elites

1. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

• A. Swollen lymph nodes in the groin
• B. Core body temperature of 100.5°F
• C. All of the above
• D. Elevated white blood cell count

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

2. An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?

• A. Monitor the client’s fluid intake.
• B. Obtain a stool sample for testing.
• C. Administer a laxative to clear the infection.
• D. Assess skin turgor and provide fluids.

Correct answer: D

Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.

3. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

• A. Administer a dose of vitamin K to reverse the effects of warfarin.
• B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
• C. Increase the client’s warfarin dosage to prevent clot formation.
• D. Notify the healthcare provider immediately and hold the next dose of warfarin.

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

4. A client with anemia is prescribed iron supplements. What teaching should the nurse provide?

• A. Take iron supplements with meals to prevent stomach upset.
• B. Take iron supplements with milk to improve absorption.
• C. Expect black, tarry stools as a side effect of iron supplements.
• D. Take iron supplements with vitamin C to improve absorption.

Correct answer: D

Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.

5. A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?

• A. Administer anticoagulant therapy as prescribed.
• B. Elevate the head of the bed to 45 degrees.
• C. Check the client's oxygen saturation.
• D. Prepare the client for a CT scan.

Correct answer: D

Rationale: The correct answer is to prepare the client for a CT scan. A CT scan is essential in confirming the presence of a pulmonary embolism (PE) and guiding further treatment. Administering anticoagulant therapy (Choice A) is important in the management of PE, but it is not the priority intervention in this case. Elevating the head of the bed (Choice B) is beneficial for optimizing oxygenation but is not the priority intervention when a PE is suspected. Checking the client's oxygen saturation (Choice C) is important, but obtaining a definitive diagnosis through a CT scan takes precedence in this situation.

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