Nursing Elites

1. Which lab value is critical for patients on warfarin therapy?

• A. Monitor INR
• B. Monitor potassium levels
• C. Monitor sodium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels for patients on warfarin therapy. INR monitoring is essential because it helps assess the clotting tendency of the blood and ensures that patients are within the therapeutic range to prevent both blood clots and excessive bleeding. Monitoring potassium levels (Choice B), sodium levels (Choice C), or platelet count (Choice D) is not specifically required for patients on warfarin therapy and does not directly impact the effectiveness or safety of the medication.

2. During an emergency response following a disaster, which client should be recommended for early discharge?

• A. A client with COPD and a respiratory rate of 44/min.
• B. A client with cancer and a sealed implant for radiation therapy.
• C. A client receiving heparin for deep-vein thrombosis.
• D. A client who is 1 day postoperative following a vertebroplasty.

Correct answer: D

Rationale: The client who is 1 day postoperative following a vertebroplasty is stable and can be discharged early. In an emergency response situation, it is crucial to prioritize clients who are medically stable and do not require immediate hospital care. The client with COPD and a respiratory rate of 44/min needs close monitoring and intervention. The client with cancer and a sealed implant for radiation therapy requires specialized care and follow-up. The client receiving heparin for deep-vein thrombosis needs ongoing anticoagulant therapy and monitoring, making early discharge not appropriate.

3. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to the same location each time.
• B. Rotate the patch site daily to avoid skin irritation.
• C. Apply the patch in the morning and remove it at bedtime.
• D. Keep the patch on at all times, even during a bath.

Correct answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

4. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

• A. Administer the injection into the muscle of your thigh.
• B. Pinch the skin before inserting the needle.
• C. Rub the injection site after administering the medication.
• D. Administer the injection into the fat tissue of your abdomen.

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

5. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

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