Nursing Elites

1. A patient is prescribed an oral anticoagulant. What should the nurse monitor for?

• A. Elevated blood glucose
• B. Decreased blood pressure
• C. Signs of bleeding
• D. Increased appetite

Correct answer: C

Rationale: Correct! When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants are medications that prevent blood clot formation but can increase the risk of bleeding. Monitoring for signs such as easy bruising, blood in urine or stool, and prolonged bleeding from minor cuts is essential. Choices A, B, and D are incorrect because oral anticoagulants do not typically affect blood glucose levels, blood pressure, or appetite.

2. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

• A. “Has your child had any sore throats?”
• B. “Has your child been eating properly?”
• C. “Is your child allergic to any antibiotics?”
• D. “Has your child been exposed to any infections?”

Correct answer: C

Rationale: The correct question the nurse should ask the mother before administering an MMR vaccine to a 15-month-old is whether the child is allergic to any antibiotics. This is crucial because vaccines like MMR contain components that the child could be allergic to, such as neomycin. Checking for antibiotic allergies is essential to prevent adverse reactions to the vaccine. The other options are less relevant in this context. Asking about sore throats, eating habits, or exposure to infections does not directly impact the administration of the MMR vaccine.

3. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

• A. Explain to the client that it is too early to have an injection for pain
• B. Call the practitioner, report the client’s symptoms, and obtain further orders
• C. Reposition the client for greater comfort and turn on the television as a distraction
• D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client’s symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.

4. What causes hepatic encephalopathy?

• A. Buildup of ammonia in the body
• B. Buildup of urea in the body
• C. Fatty infiltration of the liver
• D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body. Ammonia, a byproduct of protein metabolism, normally gets converted to urea in the liver for excretion. However, in liver dysfunction, such as cirrhosis, the liver cannot effectively convert ammonia to urea, leading to its accumulation in the body and subsequently causing hepatic encephalopathy. Choices B, C, and D are incorrect as they do not directly relate to the pathophysiology of hepatic encephalopathy.

5. Which electrolyte imbalance is a potential side effect of diuretics?

• A. Hyperkalemia
• B. Hypercalcemia
• C. Hypomagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Diuretics commonly cause hypokalemia due to increased urinary excretion of potassium. Hyperkalemia (Choice A) is the opposite, characterized by high potassium levels and is not typically associated with diuretics. Hypercalcemia (Choice B) is an elevated calcium level, which is not a common side effect of diuretics. Hypomagnesemia (Choice C) is low magnesium levels, which can be a side effect of diuretics, but the most common electrolyte imbalance associated with diuretics is hypokalemia.

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