Nursing Elites

1. A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?

• A. Determine if the AP is qualified to perform the test
• B. Help the AP perform the blood glucose test
• C. Assign the AP to ask the client if they have taken diabetic medication today
• D. Have the AP check the medical record for prior blood glucose test results

Correct answer: A

Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.

2. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

3. A nurse is providing teaching to a client who has chronic kidney disease. Which of the following client statements indicates an understanding of the teaching?

• A. I will decrease my intake of foods that are high in phosphorus
• B. I will increase my intake of foods that are high in potassium
• C. I will decrease my intake of foods that are high in iron
• D. I will increase my intake of calcium supplements

Correct answer: A

Rationale: The correct answer is A. Clients with chronic kidney disease should limit their intake of phosphorus because high phosphorus levels can lead to bone disease and cardiovascular problems. Increasing foods high in potassium (choice B) is not recommended as it can be harmful to individuals with kidney disease. Decreasing intake of foods high in iron (choice C) is not specifically indicated for chronic kidney disease. Increasing calcium supplements (choice D) may not be necessary and can potentially lead to hypercalcemia in individuals with kidney disease.

4. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?

• A. Call the provider if the respiratory rate is less than 18/min
• B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.

5. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

• A. PT and INR
• B. Blood glucose levels
• C. Complete blood count (CBC)
• D. Platelet count

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

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