Nursing Elites

1. The nurse is caring for four clients: Client A, who has emphysema and an oxygen saturation of 94%; Client B, with a postoperative hemoglobin of 8.7 g/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy with a white blood cell count of 15,000/mm3. What intervention should the nurse implement?

• A. Increase Client A's oxygen to 4 liters per minute via nasal cannula.
• B. Determine if Client B has two units of packed cells available in the blood bank.
• C. Ask the dietitian to add a banana to Client C's breakfast tray.
• D. Inform Client D that surgery is likely to be delayed until the infection is treated.

Correct answer: D

Rationale: A high white blood cell count, as seen in Client D, indicates infection, which may require postponing surgery to treat the infection adequately. It is crucial to address the underlying infection before proceeding with the appendectomy to prevent complications and ensure a successful surgical outcome.

2. A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?

• A. Avoid green leafy vegetables.
• B. Take aspirin for headaches.
• C. Use a soft-bristled toothbrush.
• D. Limit fluid intake to 1 liter per day.

Correct answer: C

Rationale: The correct instruction for a client on warfarin therapy, especially with a history of DVT, is to use a soft-bristled toothbrush. This is crucial to prevent gum bleeding, which is a risk due to the anticoagulant effects of warfarin. Green leafy vegetables are rich in vitamin K, which can interfere with warfarin's effectiveness, so they should be consumed consistently to maintain a balance. Aspirin is not recommended for headaches in clients on warfarin due to the increased risk of bleeding. Limiting fluid intake is not a standard instruction for clients on warfarin therapy.

3. A client is admitted with a diagnosis of acute pancreatitis. Which laboratory value should the nurse monitor closely?

• A. Serum amylase.
• B. Serum sodium.
• C. Serum calcium.
• D. Serum potassium.

Correct answer: A

Rationale: In acute pancreatitis, serum amylase is a crucial laboratory value to monitor closely. Elevated levels of serum amylase are a key indicator of pancreatic inflammation and can help confirm the diagnosis of acute pancreatitis. Therefore, monitoring serum amylase levels is essential for assessing the progression and severity of the condition in a client with acute pancreatitis.

4. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

5. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?

• A. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath.
• B. Administer the aspirin with at least two ounces of water or juice.
• C. Notify the healthcare provider if the child complains of ringing in the ears.
• D. Advise the parents to question the child about seeing yellow halos around objects.

Correct answer: C

Rationale: In children, ringing in the ears (tinnitus) can be a sign of aspirin toxicity. Aspirin toxicity can be particularly concerning in children and can lead to serious complications. Therefore, it is crucial for the nurse to prioritize monitoring for signs of aspirin toxicity, such as tinnitus, and promptly notify the healthcare provider if such symptoms occur.

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