Nursing Elites

1. A client is being taught about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will take this medication on an empty stomach.
• B. If I forget to take a dose, I can take it later on the same day.
• C. I will skip my dose if I forget to take it.
• D. I can take an additional dose if I miss one.

Correct answer: B

Rationale: The correct answer is B because taking warfarin later on the same day if a dose is missed helps maintain therapeutic levels. Choice A is incorrect because warfarin should be taken with food to enhance absorption. Choice C is incorrect as skipping a dose can lead to fluctuations in warfarin levels. Choice D is incorrect as taking an additional dose can increase the risk of bleeding.

2. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

• A. Confusion and disorientation that resolve with rest
• B. A blood pressure reading of 110/70
• C. Irritability and agitation that worsen throughout the day
• D. Mild confusion during the evening hours

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

3. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

4. A nurse is caring for a client who has a serum sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Numbness of the extremities.
• B. Abdominal cramping.
• C. Bradycardia.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Abdominal cramping is a common manifestation of hyponatremia, as the sodium imbalance affects muscle function. Numbness of the extremities (Choice A) is more commonly associated with electrolyte imbalances such as hypocalcemia. Bradycardia (Choice C) is not typically a direct manifestation of hyponatremia. Positive Chvostek's sign (Choice D) is related to hypocalcemia, not hyponatremia.

5. Which nursing action is best when managing a client with severe anxiety?

• A. Maintain a calm manner
• B. Help the client identify thoughts prior to the anxiety
• C. Administer anti-anxiety medication
• D. Initiate seclusion if anxiety escalates

Correct answer: A

Rationale: The correct answer is to maintain a calm manner. When managing a client with severe anxiety, the nurse's calm presence can help the client feel more secure and reduce their anxiety levels. It is essential to create a safe and supportive environment. Helping the client identify thoughts prior to anxiety (choice B) may be beneficial in cognitive-behavioral interventions but may not be the initial best action for severe anxiety. Administering anti-anxiety medication (choice C) should be done by a healthcare provider's order and is not the first-line intervention for managing severe anxiety. Initiating seclusion (choice D) should only be considered as a last resort if the client is at risk of harm to themselves or others, as it can further escalate anxiety and should not be the initial action.

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