Nursing Elites

1. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

• A. PT and INR
• B. Blood glucose levels
• C. Complete blood count (CBC)
• D. Platelet count

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

2. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

• A. Presumptive sign of pregnancy
• B. Probable sign of pregnancy
• C. Positive sign of pregnancy
• D. Possible sign of pregnancy

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

3. A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

• A. “I can expect swelling in my hands and on my face.”
• B. “The amount of protein in my blood is high.”
• C. “I might have some pain and gas in my stomach from this condition.”
• D. “I will use a soft bristle toothbrush, so my gums don’t bleed.”

Correct answer: A

Rationale: The correct answer is A: “I can expect swelling in my hands and on my face.” Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.

4. A healthcare professional is preparing to administer a flu vaccine. Which of the following should the healthcare professional verify?

• A. Client's age
• B. Client's allergy to eggs
• C. Client's vaccination history
• D. Client's weight

Correct answer: C

Rationale: The healthcare professional should verify the client's vaccination history to ensure they are due for the flu vaccine. Verifying the client's age (choice A) is important for other vaccines but not specifically for the flu vaccine. While allergy to eggs (choice B) is relevant as the flu vaccine is traditionally produced in eggs, it is not the top priority for verification. The client's weight (choice D) is not directly related to the administration of the flu vaccine.

5. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

• A. Client with cystic fibrosis who has a thick productive cough and reports thirst
• B. Client with gastroenteritis who is lethargic and confused
• C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
• D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic

Correct answer: B

Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.

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