Nursing Elites

1. A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?

• A. Hydrogen peroxide
• B. Chlorhexidine
• C. Isopropyl alcohol
• D. Chlorine bleach

Correct answer: D

Rationale: Chlorine bleach is the most appropriate agent for disinfecting surfaces contaminated with blood. It is effective in killing a wide range of pathogens, including viruses. Hydrogen peroxide (Choice A) is not as effective as chlorine bleach for bloodborne pathogen disinfection. Chlorhexidine (Choice B) and isopropyl alcohol (Choice C) are more commonly used for skin antisepsis rather than surface disinfection, making them less suitable options in this scenario.

2. A nurse is caring for a client receiving anticoagulation therapy. Which of the following should the nurse monitor?

• A. INR levels
• B. Blood glucose
• C. Serum creatinine
• D. Liver function

Correct answer: A

Rationale: Corrected Rationale: When caring for a client receiving anticoagulation therapy, the nurse should monitor the INR levels. INR (International Normalized Ratio) reflects the blood's ability to clot properly. It is crucial to monitor INR levels to ensure the anticoagulation therapy is within the therapeutic range and to prevent bleeding complications. Monitoring blood glucose levels (Choice B) is more relevant for clients with diabetes or those on medications affecting blood sugar. Serum creatinine (Choice C) is typically monitored to assess kidney function. Liver function (Choice D) is assessed through tests like AST, ALT, and bilirubin levels, and it is more relevant for assessing liver health rather than monitoring anticoagulation therapy.

3. A nurse enters a client's room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?

• A. Close the window
• B. Evacuate the room
• C. Call the fire department
• D. Attempt to extinguish the fire

Correct answer: B

Rationale: The correct answer is to evacuate the room first. In a fire situation, the priority is safety, following the RACE protocol: Rescue, Alarm, Contain, Extinguish. Evacuating the room ensures the safety of both the client and the nurse. Closing the window (Choice A) can wait until after evacuation when there is no immediate danger. Calling the fire department (Choice C) is important but comes after ensuring personal safety and evacuating. Attempting to extinguish the fire (Choice D) is not recommended as it can put the nurse and the client at risk; firefighting should be left to professionals.

4. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

5. A client has a new prescription for levothyroxine. What should the nurse teach the client?

• A. It should be taken at night
• B. Monitor for symptoms of hypothyroidism
• C. Take it with calcium supplements
• D. Take it on an empty stomach

Correct answer: D

Rationale: The correct answer is to take levothyroxine on an empty stomach. This is because levothyroxine should be taken in the morning on an empty stomach to ensure proper absorption. Option A is incorrect because levothyroxine is usually advised to be taken in the morning. Option B is not the priority teaching point as monitoring for hypothyroidism symptoms is ongoing care. Option C is incorrect as levothyroxine should not be taken with calcium supplements as they can interfere with its absorption.

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