Nursing Elites

1. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which laboratory value should the nurse monitor closely?

• A. International Normalized Ratio (INR)
• B. Serum glucose level
• C. White blood cell count
• D. Prothrombin time (PT)

Correct answer: A

Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client with atrial fibrillation to assess the effectiveness and safety of anticoagulation therapy with warfarin. Monitoring the INR helps to ensure that the client is within the therapeutic range to prevent complications such as thrombosis or bleeding. Choices B, C, and D are less relevant in this scenario. While serum glucose levels are important in assessing metabolic status, and white blood cell count and prothrombin time are important indicators for other conditions, they are not the primary focus when a client with atrial fibrillation presents with confusion.

2. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

3. The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.

4. A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?

• A. Ensure the catheter is below the level of the bladder at all times.
• B. Change the catheter bag every 48 hours.
• C. Cleanse the perineal area daily.
• D. Perform catheter care daily.

Correct answer: A

Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.

5. The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?

• A. Pupils reactive to accommodation.
• B. Nystagmus present with pupillary focus.
• C. Peripheral vision intact.
• D. Consensual pupillary constriction present.

Correct answer: A

Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.

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