Nursing Elites

1. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

2. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

• A. INR 1.8
• B. Hemoglobin 14 g/dL
• C. Platelets 175,000/mm³
• D. Potassium 3.8 mEq/L

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

3. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?

• A. Limit the client's sodium intake to 4 grams per day.
• B. Measure the client's abdominal girth daily.
• C. Monitor the client's urine specific gravity every 12 hours.
• D. Encourage the client to drink 3 liters of fluid per day.

Correct answer: B

Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.

4. A healthcare professional is preparing to administer an IV fluid bolus of 500 mL over 4 hours to a client who is dehydrated. The healthcare professional should set the IV pump to deliver how many mL/hr?

• A. 75 mL/hr.
• B. 100 mL/hr.
• C. 125 mL/hr.
• D. 150 mL/hr.

Correct answer: C

Rationale: Setting the IV pump to 125 mL/hr ensures the correct infusion rate for delivering 500 mL over 4 hours. To calculate the mL/hr rate, divide the total volume to be infused (500 mL) by the total time for infusion (4 hours): 500 mL / 4 hours = 125 mL/hr. Choice A (75 mL/hr) is too low and would result in an insufficient infusion rate, potentially delaying fluid resuscitation. Choice B (100 mL/hr) would also be too low and not deliver the fluid within the specified time frame. Choice D (150 mL/hr) is too high and would infuse the fluid too quickly, potentially causing fluid overload and complications.

5. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

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