Nursing Elites

1. A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?

• A. The ulcer has a pale-colored base.
• B. The ulcer is deep, with even edges.
• C. The ulcer has little granulation tissue.
• D. The ulcer has a brownish or 'brawny' appearance.

Correct answer: D

Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. The correct answer is not A because venous stasis ulcers typically do not have a pale-colored base. Choice B is incorrect as venous stasis ulcers usually have irregular, shallow edges, not deep and even edges. Choice C is incorrect as venous stasis ulcers often have excess granulation tissue, not little granulation tissue. Recognizing the brownish or 'brawny' appearance is crucial for accurate diagnosis and appropriate treatment of venous stasis leg ulcers.

2. The client has atrial fibrillation and is receiving warfarin (Coumadin) therapy. Which laboratory test should be monitored to evaluate the effectiveness of the warfarin therapy?

• A. Prothrombin time (PT) and international normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Complete blood count (CBC)
• D. Fibrinogen levels

Correct answer: A

Rationale: Monitoring the Prothrombin time (PT) and international normalized ratio (INR) is crucial for assessing the effectiveness of warfarin therapy. These tests help determine the clotting ability of the blood and ensure that the client is within the desired therapeutic range to prevent clotting events or bleeding complications. Activated partial thromboplastin time (aPTT) (Choice B) is more commonly used to monitor heparin therapy, not warfarin. Complete blood count (CBC) (Choice C) and fibrinogen levels (Choice D) do not directly assess the effectiveness of warfarin therapy in the same way that PT and INR do.

3. The healthcare provider is reinforcing instructions to a client with heart failure who is prescribed a low-sodium diet. The provider should advise the client to choose which food item?

• A. Canned soup
• B. Fresh vegetables
• C. Processed cheese
• D. Pickled vegetables

Correct answer: B

Rationale: Fresh vegetables are a suitable choice for clients on a low-sodium diet as they are naturally low in sodium and provide essential nutrients. In contrast, canned soup, processed cheese, and pickled vegetables tend to be high in sodium, which is not recommended for individuals with heart failure and on a low-sodium diet. Fresh vegetables are also rich in fiber, vitamins, and minerals, making them a healthier option compared to the other choices provided.

4. A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?

• A. Administer morphine
• B. Obtain an electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Administer sublingual nitroglycerin

Correct answer: B

Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action. Administering morphine without assessing the current cardiac status through an ECG can mask important diagnostic clues. Applying oxygen and administering nitroglycerin are supportive measures that can follow the ECG to address potential hypoxia and ischemic pain relief, respectively.

5. The nurse is caring for a client with heart failure who is receiving digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse monitor for?

• A. Hypertension
• B. Bradycardia
• C. Hyperglycemia
• D. Insomnia

Correct answer: B

Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin can cause bradycardia due to its effects on the heart's electrical conduction system. Monitoring for a slow heart rate is crucial as it indicates potential toxicity. Hypertension, hyperglycemia, and insomnia are not typically associated with digoxin toxicity. Hypertension is more commonly seen in other conditions, hyperglycemia is not a typical sign of digoxin toxicity, and insomnia is not a recognized symptom of digoxin toxicity.

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