Nursing Elites

1. The nurse is administering a new medication to a client. What is the priority action before administering the drug?

• A. Verify the client's allergies
• B. Check the client's blood pressure
• C. Assess the client's pain level
• D. Provide client education on the medication

Correct answer: A

Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.

2. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?

• A. Avoid foods high in vitamin K, such as spinach.
• B. Report any signs of bleeding, such as bruising or nosebleeds.
• C. Take the medication on an empty stomach.
• D. Monitor for changes in blood pressure.

Correct answer: B

Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.

3. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.

4. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

5. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?

• A. Elevate the affected leg
• B. Encourage early ambulation
• C. Perform frequent range-of-motion exercises
• D. Apply ice packs to the affected leg

Correct answer: A

Rationale: Elevating the affected leg is crucial in managing deep vein thrombosis (DVT) as it helps to reduce swelling and improve venous return. This intervention is essential for preventing complications such as pulmonary embolism. Encouraging early ambulation is generally beneficial for preventing DVT but is secondary to leg elevation. Performing range-of-motion exercises can be helpful for maintaining joint mobility but is not the priority intervention in this case. Applying ice packs to the affected leg is not recommended in DVT management as it can cause vasoconstriction and potentially worsen the condition.

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