Nursing Elites

1. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

2. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should use a soft-bristled toothbrush while taking this medication.
• C. I should take my warfarin at bedtime.
• D. I should avoid eating foods high in vitamin K while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.

3. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.

4. A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.

5. A client with type 2 diabetes mellitus is receiving metformin (Glucophage). Which laboratory test should the LPN/LVN monitor while the client is taking this medication?

• A. Complete blood count (CBC)
• B. Liver function tests
• C. Serum electrolytes
• D. Renal function tests

Correct answer: B

Rationale: The correct answer is B: Liver function tests. While a client is taking metformin, monitoring liver function tests is crucial to assess for potential hepatic side effects. Metformin is primarily eliminated by the liver, and monitoring liver function tests helps in early detection of any liver-related complications. Choices A, C, and D are incorrect. A complete blood count (CBC) is not specifically required for monitoring metformin therapy. Serum electrolytes are not directly impacted by metformin, making it less relevant for monitoring this medication. Renal function tests are important for some other diabetes medications, but in the case of metformin, liver function tests take precedence due to its hepatic metabolism.

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