Nursing Elites

1. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

• A. Bleeding time
• B. Coagulation time
• C. Prothrombin time
• D. Partial thromboplastin time

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.

2. When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?

• A. I use a damp cloth to clean the outside part of my hearing aids.
• B. I clean my hearing aids' ear molds with rubbing alcohol.
• C. I always keep the volume of my hearing aids turned up for better hearing.
• D. I remove the batteries from my hearing aids when not in use at night.

Correct answer: A

Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.

3. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

• A. "It must be difficult to care for someone who is confined to bed."
• B. "It is important to keep the client clean to avoid infections."
• C. "I understand that this is challenging; let’s work together to ensure comfort."
• D. "The smell is quite strong; we need to address this immediately."

Correct answer: C

Rationale: The correct response is C: "I understand that this is challenging; let’s work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.

4. A healthcare provider is providing discharge teaching to a client about self-administering heparin.

• A. Administer medication in the abdomen.
• B. Administer medication in the thigh.
• C. Administer medication in the upper arm.
• D. Administer medication in the buttock.

Correct answer: A

Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.

5. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Compromised host precautions

Correct answer: C

Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.

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