Nursing Elites

1. A nurse is preparing to perform a bladder scan for a client who has overflow incontinence. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Obtain a prescription for insertion of an indwelling catheter.
• C. Cleanse the client's abdomen with an antiseptic solution.
• D. Prepare the client for urinary catheterization.

Correct answer: D

Rationale: The correct answer is to prepare the client for urinary catheterization. Overflow incontinence may indicate bladder distention, where a bladder scan helps assess the need for catheterization. Placing the client in a supine position (Choice A) is not directly related to the procedure. Obtaining a prescription for an indwelling catheter (Choice B) is not necessary before performing a bladder scan. Cleansing the client's abdomen with an antiseptic solution (Choice C) is not specific to preparing for a bladder scan in this situation.

2. A nurse is providing discharge teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

• A. Avoid eating foods that are high in fat.
• B. Monitor for black, tarry stools while taking this medication.
• C. Avoid taking this medication with grapefruit juice.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to monitor for black, tarry stools while taking clopidogrel. This is important because it helps detect gastrointestinal bleeding, a potential side effect of the medication. Choice A is incorrect as there is no specific requirement to avoid foods high in fat while taking clopidogrel. Choice C is incorrect as grapefruit juice interaction is not a concern with clopidogrel. Choice D is incorrect as clopidogrel can be taken with or without food.

3. A nurse is planning care for a client with thrombocytopenia. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener is essential to prevent straining during bowel movements, which could result in bleeding for clients with thrombocytopenia. Encouraging the client to floss daily (choice A) is unrelated to the management of thrombocytopenia. Removing fresh flowers (choice B) is more relevant for clients with a compromised immune system. Avoiding serving raw vegetables (choice D) is important for clients with compromised immune systems to prevent foodborne illnesses, but it is not directly related to thrombocytopenia.

4. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.

5. Which of the following lab values indicates a patient on warfarin is at a therapeutic level?

• A. INR of 1.1
• B. PT of 12 seconds
• C. INR of 2.5
• D. Platelet count of 150,000

Correct answer: C

Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.

Similar Questions