Nursing Elites

1. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:

• A. 900
• B. 1200
• C. 1700
• D. 2100

Correct answer: C

Rationale: Sodium warfarin is typically administered in the late afternoon, around 1700 hours. This timing allows for accurate bleeding times to be drawn in the morning. Administering it at 0900 (choice A) would not align with this schedule and may affect the monitoring of bleeding times. Choice B (1200) is midday, which is not the recommended time for sodium warfarin administration. Choice D (2100) is in the evening, which is also not ideal. Therefore, the correct time for administering sodium warfarin is 1700 (choice C).

2. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?

• A. Telling the client that the medication will need to be taken with juice
• B. Telling the client that the medication will change the color of the urine
• C. Telling the client to take the medication before going to bed at night
• D. Telling the client to take the medication if night sweats occur

Correct answer: B

Rationale: The correct answer is telling the client that the medication will change the color of the urine. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is important as the client might think this is a complication. Answer A is incorrect because there is no specific requirement to take rifampin with juice. Answer C is incorrect because rifampin should be taken at consistent times, not necessarily before going to bed. Answer D is incorrect as rifampin should be taken regularly as prescribed, not based on symptoms like night sweats.

3. The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?

• A. right to refuse treatment
• B. right to continuity of care
• C. right to confidentiality
• D. right to reasonable responses to requests

Correct answer: C

Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. In this scenario, discussing a client scenario in a public elevator could potentially lead to the breach of the client's right to confidentiality. The other choices, such as the right to refuse treatment, right to continuity of care, and right to reasonable responses to requests, are not typically breached in this context. It is important to uphold client confidentiality to maintain trust and privacy in healthcare settings.

4. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's

• A. feelings about what has been described.
• B. thoughts about what has been described.
• C. possible solutions to the problem.
• D. intent in sharing the description.

Correct answer: B

Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client's thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.

5. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

• A. Cyanocobalamin
• B. Protamine sulfate
• C. Streptokinase
• D. Sodium warfarin

Correct answer: B

Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.

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