Nursing Elites

1. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

2. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

• A. Document the client's status every 60 minutes.
• B. Provide a staff member to stay with the client continuously.
• C. Measure vital signs every 4 hours.
• D. Obtain a prescription for the restraints every 8 hours.

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

3. How should a healthcare professional manage a patient with suspected infection?

• A. Monitor vital signs and administer antibiotics
• B. Check for fever and monitor white blood cell count
• C. Assess for pain and check for localized swelling
• D. Monitor for chills and administer fluids

Correct answer: A

Rationale: Correct answer: When managing a patient with suspected infection, it is crucial to monitor vital signs like temperature, heart rate, blood pressure, and respiratory rate to assess the severity of the infection. Administering antibiotics is also essential to treat the infection. Choice B is incorrect because while checking for fever and monitoring white blood cell count are important, they alone are not sufficient to manage the patient. Choice C focuses on assessing pain and localized swelling, which are important but not primary in managing suspected infection. Choice D mentions monitoring for chills and administering fluids, which are not the primary interventions for managing a suspected infection.

4. What is the first step in managing a client with delirium?

• A. Administer sedative medication to calm the client
• B. Identify any reversible causes of delirium
• C. Limit environmental stimulation to reduce anxiety
• D. Administer antipsychotic medication to control behavior

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?

• A. Monitor the client's temperature every 4 hours
• B. Monitor blood glucose levels every 6 hours
• C. Administer insulin as prescribed
• D. Monitor daily fluid intake

Correct answer: B

Rationale: Corrected Rationale: Monitoring blood glucose levels is crucial in clients receiving TPN because the solution has a high glucose content. This monitoring helps prevent hyperglycemia and allows for timely adjustments in the TPN formulation if needed. Monitoring the client's temperature (Choice A) is not directly related to TPN administration. Administering insulin (Choice C) should be based on blood glucose levels and the healthcare provider's orders; it is not a standard intervention for all clients on TPN. Monitoring daily fluid intake (Choice D) is important for overall fluid balance but is not as critical as monitoring blood glucose levels specifically for clients on TPN.

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