Nursing Elites

1. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

• A. Platelet count
• B. Prothrombin time (PT)
• C. White blood cell count
• D. Hemoglobin level

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

2. A client with chronic kidney disease is prescribed a low-sodium diet. What is the nurse's priority teaching?

• A. Choose fresh fruits and vegetables.
• B. Restrict fluid intake to 1500 mL per day.
• C. Limit sodium intake to 2 grams per day.
• D. Increase potassium intake to prevent hypokalemia.

Correct answer: C

Rationale: The correct answer is C: 'Limit sodium intake to 2 grams per day.' For a client with chronic kidney disease, limiting sodium intake is crucial because it helps prevent fluid retention and reduces the workload on the kidneys. Choice A, 'Choose fresh fruits and vegetables,' is generally a healthy dietary recommendation but not the priority when focusing on a low-sodium diet. Choice B, 'Restrict fluid intake to 1500 mL per day,' is important but secondary to limiting sodium intake. Choice D, 'Increase potassium intake to prevent hypokalemia,' is not the priority teaching for a client with chronic kidney disease on a low-sodium diet.

3. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?

• A. Monitor for signs of infection.
• B. Measure abdominal girth and monitor for pain.
• C. Check for bowel movement and changes in stool.
• D. Assess hydration status and monitor urine output.

Correct answer: C

Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.

4. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

5. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?

• A. Administer antiemetics to reduce nausea.
• B. Obtain a list of the client's cardiac medications.
• C. Perform an ECG to evaluate heart function.
• D. Review the client's dietary intake for possible causes.

Correct answer: B

Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.

Similar Questions