Nursing Elites

1. How should bleeding in a patient on warfarin be monitored?

• A. Monitor INR levels
• B. Monitor hemoglobin levels
• C. Monitor potassium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

2. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.

3. A nurse is providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?

• A. Soak the wound in warm water every day
• B. Use hydrogen peroxide to clean the wound
• C. Apply a cold compress to the wound
• D. Keep the wound covered with a dry dressing

Correct answer: D

Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.

4. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

• A. Platelet count
• B. Potassium level
• C. Creatinine clearance
• D. Prealbumin

Correct answer: A

Rationale: The correct answer is A: Platelet count. Platelet count helps assess clotting abnormalities that could cause petechiae and ecchymoses. Petechiae and ecchymoses are often associated with bleeding disorders, so it is crucial to evaluate the platelet count to determine if there is a deficiency in platelets. Choices B, C, and D are incorrect because potassium level, creatinine clearance, and prealbumin do not directly relate to assessing clotting abnormalities associated with petechiae and ecchymoses.

5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include?

• A. You should avoid consuming foods high in vitamin K.
• B. Take this medication at the same time each day.
• C. Monitor for signs of bruising and bleeding.
• D. Have your INR checked every 4 weeks.

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming foods high in vitamin K. Foods rich in vitamin K, such as leafy greens, can interfere with the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for clients on warfarin therapy to maintain consistent vitamin K intake to keep their INR levels stable. The other options are also important but not the priority in the context of warfarin therapy. Ingesting foods high in vitamin K can affect the medication's efficacy, making it crucial to highlight this dietary consideration during client education.

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