Nursing Elites

1. The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading?

• A. Frequent syncope
• B. Muscle rigidity
• C. Gait instability
• D. Fine motor tremors

Correct answer: A

Rationale: The correct answer is A: 'Frequent syncope.' Orthostatic hypotension, common in Parkinson's disease, often causes syncope (fainting) when blood pressure drops upon standing. This information is critical for planning safe blood pressure measurements, ensuring readings are taken in both lying and standing positions to assess for sudden drops in pressure. Muscle rigidity, tremors, or gait instability are important symptoms in Parkinson's disease but are not directly related to blood pressure assessment.

2. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

3. A client with chronic liver disease is prescribed lactulose. Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

• A. Bilirubin level
• B. Serum ammonia level
• C. Serum potassium level
• D. Albumin level

Correct answer: B

Rationale: The correct answer is B: Serum ammonia level. Lactulose is used to lower serum ammonia levels in clients with chronic liver disease, particularly in cases of hepatic encephalopathy. Monitoring serum ammonia levels is crucial to evaluate the effectiveness of lactulose in managing hepatic encephalopathy. Choices A, C, and D are incorrect because they are not directly related to the action or evaluation of lactulose in chronic liver disease.

4. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: The correct action for the nurse to take when a client develops urticaria during a blood transfusion is to immediately stop the infusion. Urticaria is a sign of a transfusion reaction, and stopping the infusion is crucial to prevent the reaction from worsening. Slowing the rate of infusion (Choice B) is not appropriate in this situation as the reaction has already started. While taking vital signs and observing for further deterioration (Choice C) is important, the priority is to stop the transfusion. Administering Benadryl and continuing the infusion (Choice D) is not recommended until the client's condition has stabilized and healthcare provider orders have been obtained.

5. 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.

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