Nursing Elites

1. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory values should the nurse monitor?

• A. Prothrombin time (PT)
• B. Hemoglobin
• C. aPTT
• D. INR

Correct answer: D

Rationale: The correct answer is D, INR. The International Normalized Ratio (INR) is used to monitor the therapeutic effect of warfarin and to adjust the dose as needed. While Prothrombin time (PT) and activated Partial Thromboplastin Time (aPTT) are also related to coagulation studies, monitoring INR specifically helps in managing warfarin therapy. Hemoglobin, on the other hand, is not typically monitored in relation to warfarin therapy.

2. How should a healthcare professional assess a patient's pain level post-surgery?

• A. Use a pain rating scale
• B. Check vital signs
• C. Observe for non-verbal cues
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

3. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Heart rate of 88/min.
• C. Blood pressure of 118/76 mm Hg.
• D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

4. A healthcare professional is caring for a client who has a prescription for enoxaparin. Which of the following laboratory tests should the healthcare professional review before administering the medication?

• A. Prothrombin time (PT)
• B. INR
• C. Platelet count
• D. Potassium levels

Correct answer: D

Rationale: Corrected Rationale: Before administering enoxaparin, it is essential to review potassium levels to monitor for potential imbalances. Enoxaparin, a type of anticoagulant, does not directly affect PT, INR, or platelet count. Monitoring potassium levels is crucial to ensure the safety and effectiveness of the medication. PT and INR are typically used to monitor warfarin therapy, while platelet count is essential for assessing clotting function but is not directly related to enoxaparin administration.

5. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume.
• B. Flush the tube with 0.9% sodium chloride.
• C. Elevate the head of the bed to 45 degrees.
• D. Warm the formula to body temperature.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees is the priority action before administering an enteral feeding through an NG tube. This position helps prevent aspiration by promoting proper flow and digestion of the feeding. Checking the residual volume, flushing the tube, and warming the formula are important steps but come after ensuring the client is in the correct position to minimize the risk of complications.

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