Nursing Elites

1. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

2. A healthcare professional is assessing a client in the PACU. Which finding indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: The correct answer is B: Oliguria. Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not receiving enough blood to produce an adequate amount of urine. Shivering (choice A) is a response to hypothermia or the body's attempt to generate heat. Bradypnea (choice C) refers to abnormally slow breathing rate and is not directly related to cardiac output. Constricted pupils (choice D) are more indicative of conditions affecting the nervous system or medications.

3. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice monthly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: A

Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.

4. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?

• A. Extinguish the fire
• B. Activate the fire alarm
• C. Evacuate the room
• D. Call the client’s family

Correct answer: C

Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.

5. A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:

• A. Perform weight-bearing exercises
• B. Avoid crossing the legs beyond the midline
• C. Avoid sitting in one position for prolonged periods
• D. Splint the affected area

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises strengthen bones and help prevent fractures, which is crucial for clients with osteoporosis. Choices B, C, and D are incorrect. Avoiding crossing the legs beyond the midline and avoiding sitting in one position for prolonged periods are general recommendations for preventing musculoskeletal issues but are not specific to osteoporosis. Splinting the affected area is not a standard practice for managing osteoporosis and preventing fractures.

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