Nursing Elites

1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the LPN/LVN monitor closely while the client is taking this medication?

• A. Blood glucose level
• B. Prothrombin time (PT) and INR
• C. Serum potassium level
• D. Serum creatinine level

Correct answer: B

Rationale: The LPN/LVN should closely monitor Prothrombin time (PT) and INR (Choice B) levels in a client receiving warfarin. These values are crucial to ensure the medication's effectiveness and prevent complications like bleeding. Monitoring blood glucose level (Choice A) is not directly relevant to warfarin therapy. While serum potassium level (Choice C) and serum creatinine level (Choice D) are important for other conditions or medications, they are not specifically required to be monitored when a client is on warfarin.

2. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

• A. The nurse washes with her hands held higher than her elbows.
• B. The nurse uses an alcohol-based hand rub for 30 seconds.
• C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
• D. The nurse washes her hands with soap and water for only 15 seconds.

Correct answer: A

Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.

3. When a healthcare professional makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The healthcare professional's attempt to irrigate the tube with 10ml of 0.9% NaCl was unsuccessful, so they determine that the tube was obstructed. Which of the following actions should the healthcare professional take?

• A. Notify the healthcare provider.
• B. Attempt to irrigate the tube with a larger volume of saline.
• C. Replace the NG tube with a new one.
• D. Reposition the client to see if that helps the tube drain.

Correct answer: A

Rationale: If an NG tube is obstructed and cannot be irrigated successfully, notifying the healthcare provider is the appropriate action to take for further management. This is crucial as the healthcare provider may need to assess the situation, provide guidance, or intervene with specific interventions. Attempting to irrigate the tube with a larger volume of saline (Choice B) may exacerbate the situation if the tube is truly obstructed. Replacing the NG tube with a new one (Choice C) should not be the initial action unless advised by the healthcare provider. Repositioning the client (Choice D) may not necessarily resolve the tube obstruction and should not be the primary intervention in this scenario.

4. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?

• A. I'm sure it will work if you just give it a chance.
• B. You may take any herbal remedies you bring from home.
• C. Why do you think pain medication is not going to help you?
• D. Would you like me to give you a back massage?

Correct answer: D

Rationale: In this scenario, the client has expressed that pain medication is not an option for managing pain. Offering alternative pain relief options like a back massage is appropriate because it respects the client's preferences and provides a non-pharmacological intervention to help alleviate pain. Choices A, B, and C are not as suitable: A may come across as dismissive of the client's decision, B may not be safe as herbal remedies can interact with medical treatments, and C focuses more on questioning the client's decision rather than providing immediate comfort.

5. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

• A. I think you or your partner needs to stay with the child while in the hospital.
• B. Oh, that behavior will stop in a few days.
• C. Keep in mind that for the age this is a normal response to being in the hospital.
• D. You might want to 'sneak out' of the room once the child falls asleep.

Correct answer: C

Rationale: The nurse should reassure the mother that the child's behavior is normal for their age and situation.

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