Nursing Elites

1. The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?

• A. Call the physician to request an increase in the Coumadin® dose.
• B. Administer a vitamin K injection IM and notify the physician of the results.
• C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.
• D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 P.M.

Correct answer: B

Rationale: In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin® dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin® may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.

2. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?

• A. Administer PRN anxiolytic
• B. Administer Antibiotics
• C. Reassure the client that everything is okay and offer food and beverage
• D. Determine the Glasgow Coma Scale

Correct answer: A

Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.

3. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.

4. Which is an example of a sentinel event?

• A. The terminally ill client is referred to hospice and dies 3 months later.
• B. A client receives an unordered mammogram which reveals a small cyst.
• C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
• D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.

Correct answer: D

Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.

5. The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?

• A. Hypocalcemia
• B. Hypomagnesemia
• C. Hyponatremia
• D. Hypokalemia

Correct answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (Choice A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (Choice B) and Hyponatremia (Choice C) are less likely to occur compared to hypokalemia in this condition.

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