Nursing Elites

1. A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?

• A. Platelet count of 200,000/mm³
• B. Hemoglobin level of 15 g/dL
• C. Respiratory rate of 22/min
• D. Dark, tarry stools

Correct answer: D

Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.

2. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

3. A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?

• A. Use latex gloves when administering the medication.
• B. Use latex-free syringes when administering the medication.
• C. Administer the medication through a latex-free IV port.
• D. Administer the medication with a latex-free syringe.

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This is crucial as it prevents direct contact of the medication with latex, reducing the risk of an allergic reaction. Choice A is incorrect as using latex gloves can still expose the client to latex. Choice B is not the best option since the administration route is not specified, and using a latex-free syringe alone may not be sufficient to prevent exposure. Choice D is not the most appropriate because the IV tubing and ports should also be latex-free to ensure complete avoidance of latex contact.

4. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

5. How should a healthcare professional administer a subcutaneous injection?

• A. Insert the needle at a 45-degree angle
• B. Insert the needle at a 90-degree angle
• C. Use a Z-track method
• D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

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