Nursing Elites

1. A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?

• A. Avoid eating foods high in potassium.
• B. Avoid foods high in vitamin K.
• C. Take the medication on an empty stomach.
• D. Take the medication at bedtime for best results.

Correct answer: B

Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.

2. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

• A. Nutritional guidelines to support blood health
• B. Signs of infection to monitor for
• C. When to give pain medication
• D. Instructions about how much fluid the child should drink daily

Correct answer: D

Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.

3. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

• A. Administer a dose of vitamin K to reverse the effects of warfarin.
• B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
• C. Increase the client’s warfarin dosage to prevent clot formation.
• D. Notify the healthcare provider immediately and hold the next dose of warfarin.

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

4. A young male client is admitted to rehabilitation following a right AKA (above-the-knee amputation) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his 'right foot is aching.' The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

• A. Teach the client distraction techniques
• B. Provide a soft blanket to ease discomfort
• C. Administer prescribed pain medication
• D. Encourage discussion of feelings about the loss of his limb

Correct answer: D

Rationale: The client's report of pain in a missing limb is consistent with phantom limb pain, which can be distressing. Encouraging the client to discuss his feelings helps address the emotional and psychological aspects of the amputation and supports his overall recovery. Teaching distraction techniques (choice A) may provide temporary relief but does not address the underlying emotional distress. Providing a soft blanket (choice B) is not the priority when dealing with phantom limb pain. Administering pain medication (choice C) may not effectively manage phantom limb pain as it is more related to central nervous system changes rather than tissue damage.

5. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

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