Nursing Elites

1. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?

• A. Avoid foods rich in vitamin K
• B. Take warfarin with meals
• C. Take aspirin for pain relief
• D. Report unusual bleeding or bruising

Correct answer: D

Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.

2. How can a healthcare professional help prevent pressure ulcers in an immobile patient?

• A. Ensuring proper nutrition and hydration
• B. Using moisture barriers to protect the skin
• C. Turning the patient every 2 hours to prevent pressure
• D. Providing special mattresses or padding

Correct answer: A

Rationale: Ensuring proper nutrition and hydration is crucial in preventing pressure ulcers in immobile patients. Adequate nutrition supports tissue health and repair, while hydration helps maintain skin elasticity. While turning the patient every 2 hours is important to prevent pressure injuries, it is not the primary way to address prevention. Using moisture barriers and providing special mattresses or padding are essential components of pressure ulcer prevention, but they are not as fundamental as ensuring proper nutrition and hydration.

3. A nurse is teaching a client who has a new prescription for digoxin. Which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

• A. Increased appetite
• B. Rash on the face
• C. Yellow-tinged vision
• D. Weight gain

Correct answer: C

Rationale: The correct answer is C: 'Yellow-tinged vision.' Yellow-tinged vision is a characteristic sign of digoxin toxicity, indicating an overdose of the medication. This visual disturbance is a critical adverse effect that should be reported promptly to the healthcare provider to prevent serious complications.\n\nChoice A, 'Increased appetite,' is not typically associated with digoxin use and is not a common adverse effect.\n\nChoice B, 'Rash on the face,' is also not a common adverse effect of digoxin. Skin rash is not a typical manifestation of digoxin toxicity.\n\nChoice D, 'Weight gain,' is not a common adverse effect of digoxin. Weight gain is not a typical symptom of digoxin toxicity and is unlikely to be related to the medication.

4. A patient prescribed warfarin is being taught about dietary restrictions by a healthcare provider. Which of the following foods should the patient be instructed to limit?

• A. Bananas
• B. Spinach
• C. Potatoes
• D. Apples

Correct answer: B

Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin, an anticoagulant medication. Patients taking warfarin should limit foods high in vitamin K to maintain the medication's effectiveness and consistent dosage. Bananas, potatoes, and apples are not high in vitamin K and do not typically interfere with warfarin therapy.

5. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

• A. Use a standardized tool such as the Braden Scale.
• B. Limit the amount of fluid intake.
• C. Have special times for inspection so as not to interrupt routine care.
• D. Assess the skin every 4 hours.

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

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