Nursing Elites

1. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

• A. White blood cell count.
• B. Prothrombin time (PT) and International Normalized Ratio (INR).
• C. Hemoglobin and hematocrit.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.

2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?

• A. As you urinate more, you will need less medication to control fluid.
• B. You will have to take this medication for about a year.
• C. The medication must be continued so the fluid problem is controlled.
• D. Please talk to your health care provider about medications and treatments.

Correct answer: C

Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.

3. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

4. Which dietary instruction is most important for a client with renal disease?

• A. Avoid all protein-rich foods.
• B. Limit fluid intake to 1500 ml/day.
• C. Increase potassium intake to prevent weakness.
• D. Eat small, frequent meals high in carbohydrates.

Correct answer: B

Rationale: The most important dietary instruction for a client with renal disease is to limit fluid intake to 1500 ml/day. This is essential to prevent fluid overload, manage electrolyte balance, and reduce strain on the kidneys. Choice A is incorrect because while protein restriction may be necessary in some cases, avoiding all protein-rich foods is not recommended as some protein intake is essential for overall health. Choice C is incorrect because increasing potassium intake is generally not advised for clients with renal disease, as they often need to limit potassium intake. Choice D is also incorrect because while consuming small, frequent meals may be helpful, emphasizing a diet high in carbohydrates is not typically the primary focus for clients with renal disease.

5. A client with hypertension is prescribed hydrochlorothiazide. What teaching should the nurse provide?

• A. Take the medication in the morning to avoid frequent urination at night.
• B. Increase fluid intake to prevent dehydration.
• C. Avoid potassium-rich foods, such as bananas and oranges.
• D. Monitor the client’s potassium levels weekly.

Correct answer: B

Rationale: The correct teaching for a client prescribed hydrochlorothiazide is to increase fluid intake to prevent dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalances, so adequate fluid intake is crucial. Choice A is incorrect because hydrochlorothiazide is typically taken in the morning to avoid nighttime urination. Choice C is incorrect as potassium-rich foods should not be avoided but monitored, as hydrochlorothiazide can cause potassium loss. Choice D is incorrect as potassium levels should be monitored regularly, but not necessarily weekly, unless indicated by the healthcare provider.

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