Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

2. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?

• A. Increase the dosage of the medication.
• B. Auscultate bowel sounds.
• C. Monitor the client's blood pressure.
• D. Check the client's respiratory rate.

Correct answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

3. Before a client with renal failure undergoes hemodialysis, what should the nurse assess?

• A. Check the client's potassium levels
• B. Review the client's medication list
• C. Assess the client's peripheral pulses
• D. Monitor the client's urine output

Correct answer: A

Rationale: The correct answer is to check the client's potassium levels. Potassium levels are crucial to assess before hemodialysis in a client with renal failure because hyperkalemia (high potassium) is a common complication in these patients. Hemodialysis aims to remove excess potassium from the blood, making it essential to monitor potassium levels to determine the need for appropriate interventions. Reviewing the client's medication list (Choice B) is important for overall care but is not as directly relevant to the immediate concerns before hemodialysis. Assessing peripheral pulses (Choice C) and monitoring urine output (Choice D) are important aspects of nursing assessment but are not as directly related to the specific preparation needed before hemodialysis in a client with renal failure.

4. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

5. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.

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