Nursing Elites

1. A nurse is preparing to administer a dose of warfarin. Which of the following should the nurse do?

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

Correct answer: A

Rationale: The correct answer is to check INR levels. Before administering warfarin, it is crucial to check the INR levels to ensure they are within the therapeutic range. This helps to prevent complications such as bleeding or clotting. Choice B, administering it with food, is incorrect as warfarin should typically be taken on an empty stomach. Choice C, monitoring blood glucose, is unrelated to the administration of warfarin. Choice D, assessing liver function, is important but not the immediate action required before administering warfarin.

2. A community health nurse is reviewing primary prevention for West Nile virus with a group of patients in a rural health clinic. What instructions should the nurse include?

• A. Eliminate areas of standing water.
• B. Wear a mask when outdoors.
• C. Ensure food is cooked thoroughly.
• D. Avoid contact with sick individuals.

Correct answer: A

Rationale: The correct answer is A: 'Eliminate areas of standing water.' Standing water provides breeding grounds for mosquitoes, which spread West Nile virus. By eliminating standing water, individuals can reduce the risk of mosquito breeding and the transmission of the virus. Choices B, C, and D are incorrect. Wearing a mask when outdoors, ensuring food is cooked thoroughly, and avoiding contact with sick individuals are not directly related to primary prevention strategies for West Nile virus.

3. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?

• A. Administer calcium gluconate IV
• B. Increase the magnesium sulfate infusion
• C. Administer IV fluids
• D. Administer hydralazine

Correct answer: A

Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.

4. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

• A. Redness at the site
• B. Warmth around the site
• C. Edema
• D. Pain at the site

Correct answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.

5. When educating a patient on the use of levodopa-carbidopa, which information should the nurse include?

• A. It is a cure for Parkinson's disease
• B. Monitor for dyskinesia
• C. It can be taken at any time
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is B: 'Monitor for dyskinesia.' Levodopa-carbidopa can cause dyskinesia as a side effect, which is characterized by involuntary muscle movements. Patients need to be monitored for this adverse effect and instructed to report it to their healthcare provider. Choices A, C, and D are incorrect because levodopa-carbidopa is not a cure for Parkinson's disease, it should be taken at specific times for optimal effect, and it does have side effects, such as dyskinesia.

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