Nursing Elites

1. A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?

• A. Complete blood count (CBC)
• B. Prothrombin time (PT)/INR
• C. Partial thromboplastin time (PTT)
• D. Serum potassium level

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT)/INR. Warfarin affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time (PT) and international normalized ratio (INR) is crucial to assess the effectiveness and safety of warfarin therapy. These tests help determine if the patient is within the desired anticoagulation range to prevent either clotting issues or excessive bleeding.

2. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which pre-dialysis assessment finding should the nurse report to the healthcare provider?

• A. Serum potassium of 5.5 mEq/L.
• B. Blood pressure of 180/90 mm Hg.
• C. Heart rate of 80 beats per minute.
• D. Serum sodium of 140 mEq/L.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 180/90 mm Hg is elevated and should be reported to the healthcare provider before hemodialysis. Hypertension can have a significant impact on the effectiveness and safety of the dialysis treatment. Controlling blood pressure before the procedure is crucial to prevent complications during the dialysis session.

3. The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?

• A. Intermittent bubbling in the water seal chamber.
• B. Drainage of 75 ml in the first hour post-insertion.
• C. Crepitus around the insertion site.
• D. Fluctuation of the water level in the water seal chamber with respiration.

Correct answer: C

Rationale: Crepitus (subcutaneous emphysema) around the insertion site can indicate air leakage, requiring immediate intervention to prevent complications such as pneumothorax. This assessment finding suggests that there may be a break in the chest tube system, leading to air entering the pleural space. Prompt intervention is crucial to prevent respiratory compromise and further complications.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving prednisone (Deltasone). Which side effect should the nurse monitor for?

• A. Hypoglycemia
• B. Infection
• C. Hypotension
• D. Weight loss

Correct answer: B

Rationale: The correct answer is B: Infection. Prednisone is an immunosuppressant medication commonly used in COPD to reduce inflammation. Due to its immunosuppressive effects, clients are at an increased risk of developing infections. Therefore, nurses should closely monitor clients receiving prednisone for signs and symptoms of infections to provide timely interventions.

5. What nursing intervention can help alleviate pruritus in a client with cirrhosis?

• A. Administering antihistamines
• B. Providing a high-protein diet
• C. Applying emollients to the skin
• D. Encouraging frequent baths with hot water

Correct answer: C

Rationale: Applying emollients to the skin can help alleviate pruritus in clients with cirrhosis. Emollients help soothe and moisturize the skin, reducing the discomfort associated with itching.

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