Nursing Elites

1. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice monthly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: A

Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.

2. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

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

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

3. A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?

• A. Confusion
• B. Thirst
• C. Diaphoresis
• D. Shakiness

Correct answer: B

Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.

4. When caring for a client with a sealed radiation implant, which action should be included in the plan of care?

• A. Remove dirty linens after double bagging them
• B. Wear a dosimeter film badge while in the client’s room
• C. Limit visitors to 1 hour per day
• D. Ensure family members remain at least 3 feet from the client

Correct answer: B

Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. This is crucial for monitoring radiation exposure levels when caring for a client with a sealed radiation implant. Option A is incorrect as removing dirty linens after double bagging them is not directly related to radiation safety. Option C is incorrect as there is no specific guideline to limit visitors to 1 hour per day for clients with sealed radiation implants. Option D is incorrect as the distance of family members from the client is not a primary safety measure when dealing with sealed radiation implants.

5. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

• A. Stop the infusion.
• B. Slow the infusion.
• C. Apply a warm compress to the site.
• D. Apply a cold compress to the site.

Correct answer: A

Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.

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