Nursing Elites

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Prothrombin time (PT)
• B. Hemoglobin level
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

2. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.

3. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

• A. Crackles in the lungs
• B. Shortness of breath
• C. Elevated liver enzymes
• D. Heart rate of 100 beats per minute

Correct answer: C

Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.

4. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.

5. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

Similar Questions