Nursing Elites

1. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

2. A client is receiving warfarin for atrial fibrillation. Which of the following laboratory tests should the nurse expect to be ordered to monitor the effect of warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Prothrombin time (PT)
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). When a client is on warfarin therapy, the INR is monitored regularly to assess the anticoagulant effects of the medication. A therapeutic INR range for most indications is between 2.0 to 3.0. Choices A, C, and D are not typically used to monitor the effect of warfarin. Platelet count assesses the number of platelets in the blood, PT measures the clotting time of plasma, and PTT evaluates the intrinsic pathway of coagulation.

3. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to breathe deeply and cough every 4 hours.
• B. Provide a diet that is high in carbohydrates and low in protein.
• C. Teach the client pursed-lip breathing technique.
• D. Restrict the client's fluid intake to 1,500 mL per day.

Correct answer: C

Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.

4. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to the same location each time.
• B. Rotate the patch site daily to avoid skin irritation.
• C. Apply the patch in the morning and remove it at bedtime.
• D. Keep the patch on at all times, even during a bath.

Correct answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

5. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?

• A. Share personal opinions to help influence the group's values.
• B. Measure the accomplishments of the group against a previous group.
• C. Yield in situations of conflicts to maintain group harmony.
• D. Use modeling to help the clients improve their interpersonal skills.

Correct answer: D

Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.

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