Nursing Elites

1. An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?

• A. Serum creatinine of 2.0 mg/dL
• B. Elevated WBC count
• C. Blood pressure of 100/60 mmHg
• D. Oxygen saturation of 95%

Correct answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage. Elevated WBC count (choice B) is a common feature of SIRS and may not be as urgently indicative of immediate organ damage as high creatinine levels. A blood pressure of 100/60 mmHg (choice C) is relatively low but may be a typical finding in SIRS; however, renal function is critical in this context. Oxygen saturation of 95% (choice D) is within normal limits and is not as concerning as a high creatinine level in this scenario.

2. A client with diabetes mellitus is admitted with an infected foot ulcer. What intervention is most important for the nurse to implement?

• A. Obtain a wound culture for testing.
• B. Administer prescribed IV antibiotics.
• C. Elevate the affected foot to reduce swelling.
• D. Consult the wound care nurse for assessment.

Correct answer: B

Rationale: Administering prescribed IV antibiotics is the most crucial intervention in managing an infected foot ulcer in a client with diabetes mellitus. Antibiotics help combat the infection and prevent its spread systemically, which is vital in diabetic clients to prevent serious complications like sepsis. While obtaining a wound culture (Choice A) may provide valuable information for targeted antibiotic therapy, administering antibiotics promptly takes precedence to prevent the infection from worsening. Elevating the affected foot (Choice C) can help reduce swelling but is not as urgent as administering antibiotics. Consulting the wound care nurse (Choice D) may be beneficial for long-term wound management but does not address the immediate need to control the infection.

3. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?

• A. Encourage the client to take large bites of food
• B. Advise the client to eat quickly to prevent fatigue
• C. Offer the client thin liquids with meals
• D. Instruct the client to sit upright while eating

Correct answer: D

Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.

4. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

• A. Take the medication with food to improve absorption.
• B. Avoid taking other pain medications to prevent liver damage.
• C. Take acetaminophen on an empty stomach to prevent stomach upset.
• D. Monitor liver function tests regularly to detect any liver damage.

Correct answer: B

Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.

5. A client with atrial fibrillation is prescribed warfarin. What is the most important instruction the nurse should give?

• A. Take the medication with aspirin to improve effectiveness.
• B. Increase intake of green leafy vegetables to support the medication.
• C. Avoid foods high in potassium to reduce bleeding risk.
• D. Avoid alcohol and over-the-counter medications without consulting the provider.

Correct answer: D

Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.

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