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 home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

• A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
• B. A client with a healing surgical wound
• C. A client requiring wound dressing change
• D. A client with stable vital signs needing medication administration

Correct answer: A

Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.

3. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

4. While assisting a male client with muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

• A. Place a portable toilet next to the bed.
• B. Assist the client with walking exercises.
• C. Provide pain medication as prescribed.
• D. Apply a heating pad to the affected hip.

Correct answer: A

Rationale: Placing a portable toilet next to the bed is the most appropriate intervention in this situation. It reduces the need for the client to walk long distances, thereby preventing falls and reducing discomfort. Choice B, assisting with walking exercises, would not be suitable for a client with muscular dystrophy who is experiencing awkwardness and clumsiness. Choice C, providing pain medication, may address the symptom but does not directly address the issue of reducing the need for walking. Choice D, applying a heating pad, may provide temporary relief but does not address the underlying issue of mobility and fall prevention.

5. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

• A. Auscultate the client's bowel sounds
• B. Observe for edema around the ankles
• C. Measure the client's capillary glucose level
• D. Count the apical and radial pulses simultaneously

Correct answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

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