Nursing Elites

1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?

• A. Support the client by praising her progress.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client about the effectiveness of antidepressant drugs.
• D. Advise the client to keep her belongings for discharge.

Correct answer: B

Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.

2. A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

• A. Lower the right arm below the level of the heart.
• B. Elevate the right arm on a pillow.
• C. Apply a tourniquet above the insertion site.
• D. Apply a warm compress to the insertion site.

Correct answer: A

Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.

3. A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?

• A. White blood cell count of 10,000/mm³
• B. Hemoglobin of 12 g/dL
• C. Liver function tests
• D. Platelet count of 150,000/mm³

Correct answer: C

Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.

4. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

• A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
• B. Stop the NGT feed and notify the healthcare provider
• C. Increase the NGT suction pressure
• D. Elevate the head of the bed

Correct answer: A

Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.

5. A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Heart rate of 58 beats per minute
• B. Presence of a new murmur
• C. INR of 2.5
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.

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