Nursing Elites

1. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

2. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?

• A. Obtain a blood sample to determine if the client is HIV positive
• B. Send the family to the waiting area while conducting a head-to-toe assessment
• C. Complete a head-to-toe assessment to identify other signs of HIV
• D. Ask the family members to wear gloves when touching the client

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.

3. To evaluate the medication’s effectiveness in a client with a respiratory tract infection, which laboratory values should the nurse monitor?

• A. White blood cell (WBC) count
• B. Sputum culture and sensitivity
• C. Droplet precautions
• D. Protective environment

Correct answer: A

Rationale: The correct answer is A: White blood cell (WBC) count. Monitoring the WBC count helps assess the overall response to infection and the effectiveness of the antibiotic. Sputum culture and sensitivity (choice B) are also important to confirm if the antibiotic is targeting the specific pathogen. Choices C and D, droplet precautions and protective environment, are not laboratory values but rather infection control measures that do not directly evaluate the medication's effectiveness in treating the infection.

4. A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)

• A. 4.5
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.

5. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

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