Nursing Elites

1. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

• A. increased platelet count
• B. increased fibrinogen
• C. decreased fibrin split products
• D. decreased bleeding

Correct answer: B

Rationale: Effective Heparin therapy should halt the process of intravascular coagulation, leading to increased availability of fibrinogen. Heparin interferes with thrombin-induced conversion of fibrinogen to fibrin. Therefore, an increased fibrinogen level indicates a positive response to Heparin therapy. While increased platelet count and decreased bleeding are positive outcomes, the specific indicator for Heparin therapy response is the increase in fibrinogen level. Decreased fibrin split products would also be a positive response, but an increase in fibrinogen directly reflects the impact of Heparin therapy.

2. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

• A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
• B. Hold medications and notify the physician
• C. Arouse the client and give some orange juice with sugar packets added
• D. Give the medications as ordered and re-check blood sugar in one hour

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

3. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?

• A. Secure the restraints to the bed rails on all extremities.
• B. Notify the physician that restraints have been placed properly.
• C. Communicate with the patient and family the need for restraints.
• D. Position the head of the bed at a 45-degree angle.

Correct answer: C

Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.

4. Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?

• A. If the oral tablets are not successful, the medication will be administered intravenously.
• B. The couple should engage in coitus at least every other day during treatment.
• C. The physician should be notified immediately if breast engorgement occurs.
• D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.

Correct answer: D

Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.

5. A patient has been ordered to receive Klonopin for the first time. Which of the following side effects is not associated with Klonopin?

• A. Drowsiness
• B. Ataxia
• C. Salivation elevation
• D. Diplopia

Correct answer: D

Rationale: The correct answer is 'Diplopia.' While drowsiness, ataxia, and salivation elevation are common side effects associated with Klonopin, diplopia is not typically linked to this medication. Diplopia, or double vision, is not a common side effect reported with the use of Klonopin. It is important to monitor patients for the known side effects such as drowsiness, ataxia, and salivation elevation when administering Klonopin. Choice A, B, and C are incorrect as they are known side effects of Klonopin, unlike diplopia which is not commonly observed with this medication.

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