Nursing Elites

1. A patient with chronic renal failure should avoid which of the following?

• A. Potassium
• B. Calcium
• C. Iron
• D. Zinc

Correct answer: A

Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys may not effectively filter excess potassium from the blood, leading to hyperkalemia. Calcium, iron, and zinc do not need to be avoided specifically in chronic renal failure unless there are other underlying reasons or complications.

2. Which vitamin deficiency is commonly associated with prolonged antibiotic use?

• A. Vitamin A
• B. Vitamin B6
• C. Vitamin C
• D. Vitamin K

Correct answer: D

Rationale: The correct answer is Vitamin K. Prolonged antibiotic use can disrupt the gut flora, which is responsible for synthesizing Vitamin K. This disruption can lead to a Vitamin K deficiency and an increased risk of bleeding. Vitamin A, B6, and C deficiencies are not typically associated with prolonged antibiotic use.

3. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: The correct answer is C. Turning the client to the unaffected side helps prevent complications such as pressure ulcers. Dorsiflexion of the foot on the affected leg helps maintain proper alignment and prevent foot drop. The incorrect choices are A and D. Removing the foam boot multiple times per day can disrupt traction, and asking the client to dorsiflex the foot may not be appropriate without ensuring proper alignment and direction from the healthcare provider.

4. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment when assessing the site
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to allow the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.

5. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip before initiating the Coumadin
• B. Check the client’s INR before beginning Coumadin
• C. Clarify the order with the healthcare provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct answer is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip before initiating Coumadin can increase the risk of clot formation. Checking the client's INR before starting Coumadin is important but not the immediate action required. Clarifying the order with the healthcare provider is not necessary as both medications are commonly used together.

Similar Questions