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. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

• A. A tuna fish sandwich with chips and ice cream
• B. A vegetable salad with croutons and ranch dressing
• C. A grilled chicken breast with steamed vegetables
• D. A peanut butter and jelly sandwich with soda

Correct answer: C

Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.

3. A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?

• A. Productive cough with yellow sputum.
• B. Oxygen saturation of 88%.
• C. Respiratory rate of 20 breaths per minute.
• D. Heart rate of 90 beats per minute.

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.

4. When asking an unlicensed assistive personnel (UAP) to assist a 69-year-old surgical client to ambulate for the first time, which statement by the nurse is appropriate?

• A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
• B. If the client is dizzy on standing, ask him to take some deep breaths.
• C. Assist the client to the bathroom at least twice on this shift.
• D. After you assist him to the chair, let me know how he feels.

Correct answer: A

Rationale: The correct answer is A. Allowing the client to sit on the side of the bed before standing helps prevent dizziness and falls, especially during their first ambulation post-surgery. Choice B is incorrect because asking the client to take deep breaths when feeling dizzy may not address the underlying cause of the dizziness. Choice C is incorrect as it is unrelated to the task of assisting the client to ambulate for the first time. Choice D is incorrect because knowing how the client feels after sitting in the chair does not address the important step of assisting the client to stand up for the first time.

5. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

• A. Assign an RN to supervise a nursing assistant for skin care
• B. Assign a nursing assistant to help the client with self-care activities
• C. Delegate complete care to an unlicensed assistive personnel
• D. Supervise a nursing assistant for skin care

Correct answer: D

Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.

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