Nursing Elites

1. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?

• A. I will avoid leafy green vegetables while taking warfarin.
• B. I will have my INR checked regularly while taking warfarin.
• C. I will use a soft toothbrush while taking warfarin.
• D. I will take this medication at the same time each day.

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables because they are high in vitamin K, which can interfere with the effectiveness of warfarin by counteracting its anticoagulant effects. Choices B, C, and D are all correct statements related to taking warfarin. Regular INR monitoring is necessary to ensure the medication is within the therapeutic range, using a soft toothbrush reduces the risk of bleeding gums, and taking the medication at the same time daily helps maintain consistent blood levels.

2. A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• 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 to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.

3. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

4. A healthcare provider is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the healthcare provider identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Yellow-tinged vision.
• C. Constipation.
• D. Hypertension.

Correct answer: B

Rationale: Yellow-tinged vision is a classic sign of digoxin toxicity due to its effect on the eyes. It can cause a yellow or green visual halo around objects. Bradycardia, constipation, and hypertension are not typical signs of digoxin toxicity. Bradycardia may be a sign of digoxin's therapeutic effect in heart failure, while constipation and hypertension are not commonly associated with digoxin toxicity.

5. A nurse is caring for a client who has Raynaud's disease. What intervention should the nurse implement?

• A. Provide information about stress management.
• B. Maintain a cool temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress management techniques can help reduce the frequency and severity of Raynaud's episodes. Choice B is incorrect because maintaining a cool temperature can exacerbate symptoms in individuals with Raynaud's disease. Choice C is incorrect as epinephrine is not typically used for Raynaud's disease. Choice D is incorrect as glucocorticoid steroids are not the first-line treatment for Raynaud's disease.

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