Nursing Elites

1. A healthcare professional is preparing to administer a dose of warfarin. Which of the following actions should the healthcare professional take?

• A. Verify INR levels
• B. Administer with food
• C. Monitor blood glucose levels
• D. Assess liver function

Correct answer: A

Rationale: Corrected Rationale: When administering warfarin, it is crucial to verify the patient's INR levels. INR monitoring is essential to ensure that the patient is receiving the correct dose of warfarin for their condition and to minimize the risk of bleeding. Choices B, C, and D are incorrect because administering warfarin with food, monitoring blood glucose levels, and assessing liver function are not directly related to the safe administration and monitoring of warfarin therapy.

2. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm³
• C. Rebound tenderness over McBurney’s point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen is a concerning sign indicating the possibility of a ruptured appendix and peritonitis, which are medical emergencies. Reporting this finding immediately is crucial for prompt intervention. Choice B, an elevated WBC count, could indicate infection but is not as urgent as the risk of a ruptured appendix. Choice C, rebound tenderness over McBurney’s point, is a classic sign of appendicitis but does not indicate an immediate threat like a possible rupture. Choice D, a slightly elevated temperature, is a nonspecific finding and not as critical as the risk of peritonitis associated with a distended, board-like abdomen.

3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

• A. Contraction frequency every 3 minutes
• B. Contraction duration of 100 seconds
• C. Fetal heart rate with moderate variability
• D. Fetal heart rate of 118/min

Correct answer: B

Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.

4. A nurse is preparing to administer regular insulin and NPH insulin. What is the proper sequence of events the nurse should follow?

• A. Inspect the vials for contamination.
• B. Withdraw regular insulin first, then NPH.
• C. Inject air into the NPH insulin vial first.
• D. Roll the NPH insulin vial between the hands to mix.

Correct answer: A

Rationale: The correct sequence of events for administering regular insulin and NPH insulin begins with inspecting the vials for contamination to ensure patient safety. Rolling the NPH insulin vial between the hands to mix and injecting air into the NPH insulin vial should follow the inspection step. Afterward, the nurse should inject air into the regular insulin vial and then withdraw the regular insulin first. Option A is the correct answer as it outlines the initial crucial step in the administration process. Option B is incorrect as it provides the incorrect order of withdrawing the insulins. Option C is incorrect as injecting air into the NPH insulin vial should come after inspecting the vials. Option D is incorrect as rolling the NPH insulin vial should be done after inspecting the vials and injecting air into the NPH insulin vial.

5. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

• A. Vesicle
• B. Macule
• C. Papule
• D. Nodule

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

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