Nursing Elites

1. A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?

• A. I will need to increase my intake of leafy green vegetables.
• B. I will avoid drinking grapefruit juice while taking warfarin.
• C. I will have my INR checked regularly.
• D. I will take my medication at the same time each day.

Correct answer: C

Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.

2. A healthcare professional is reviewing a client's admission laboratory results. Which of the following findings requires further evaluation?

• A. Sodium 138
• B. Creatinine 1.8
• C. Hemoglobin 15
• D. Potassium 4.2

Correct answer: B

Rationale: The correct answer is B. An elevated creatinine level, such as 1.8, suggests potential kidney dysfunction, requiring further assessment. Sodium level within normal limits (135-145 mEq/L), hemoglobin level of 15 g/dL, and potassium level of 4.2 mEq/L are all within normal ranges and do not indicate immediate concerns. Therefore, they do not require further evaluation at this time.

3. A client who practices Orthodox Judaism informs the nurse that he cannot eat certain foods during the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Serve chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

4. What is the initial intervention for a patient experiencing an allergic reaction?

• A. Administer antihistamines
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.

5. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in the microwave prior to administration

Correct answer: A

Rationale: The correct answer is to administer the feeding over 30 minutes. This slow administration helps prevent complications like nausea. Placing the child in a supine position after the feeding can increase the risk of aspiration, making choice B incorrect. Changing the feeding bag and tubing every 3 days is important for infection control and hygiene but is not directly related to the administration process, making choice C incorrect. Warming the formula in the microwave is not recommended as it can create hot spots that may burn the child's mouth or esophagus, so choice D is incorrect.

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