Nursing Elites

1. What is the first action to take when a patient experiences a seizure?

• A. Protect the patient from injury
• B. Administer oxygen
• C. Administer IV fluids
• D. Administer anti-seizure medication

Correct answer: A

Rationale: The first action to take when a patient experiences a seizure is to protect the patient from injury. This is crucial to prevent harm during the seizure. Administering oxygen, IV fluids, or anti-seizure medication may be necessary based on the patient's condition, but ensuring their safety by removing harmful objects, cushioning their head, and keeping the area clear is the immediate priority. Administering oxygen, IV fluids, or medication would come after ensuring the patient's safety.

2. Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor glucose levels

Correct answer: A

Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.

3. A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.

4. A nurse is caring for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?

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

Correct answer: D

Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.

5. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr
• B. Montevideo units consistently at 300 mm Hg
• C. FHR pattern with absent variability
• D. Contractions every 5 minutes that last 30 seconds

Correct answer: D

Rationale: The correct answer is D because contractions every 5 minutes that last 30 seconds indicate that the rate of infusion should be increased. This pattern suggests weak contractions or intervals that are too far apart, requiring an adjustment to improve labor progress. Option A is incorrect as a low urine output is not directly related to the need for an increase in the oxytocin infusion rate. Option B, Montevideo units consistently at 300 mm Hg, is incorrect because it is a measure of intrauterine pressure and does not determine the need for an increase in oxytocin infusion. Option C, FHR pattern with absent variability, is incorrect as it may indicate fetal distress but does not specifically relate to the need for adjusting the oxytocin infusion rate.

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