Nursing Elites

1. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?

• A. Test a stool specimen for occult blood
• B. Assist with the ambulation of a client with a chest tube
• C. Irrigate and redress a leg wound
• D. Admit a client from the emergency room

Correct answer: C

Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.

2. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

3. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct answer is side-lying on the left with the head elevated 10 degrees. This position maximizes ventilation and promotes better perfusion to the unaffected lung. Placing the client in this position helps to optimize oxygenation and reduce pressure on the affected lung. Choices B, C, and D are incorrect because lying on the left side with the head elevated is essential to facilitate better lung expansion and gas exchange in the unaffected lung, while lying on the right side could further compromise the affected lung by increasing pressure on it.

4. A client with a history of type 2 diabetes is admitted with hyperglycemia. What is the nurse's priority action?

• A. Administer a dose of insulin as prescribed.
• B. Check the client's blood glucose level.
• C. Administer a fluid bolus to improve hydration.
• D. Monitor the client's intake and output closely.

Correct answer: B

Rationale: The correct answer is to check the client's blood glucose level. This is the priority action when dealing with a client admitted with hyperglycemia. Checking the blood glucose level helps determine the severity of hyperglycemia and guides further treatment. Administering insulin or fluids or monitoring intake and output are important interventions but should come after assessing the blood glucose level to inform the most appropriate course of action.

5. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

• A. Platelet count
• B. Prothrombin time (PT)
• C. White blood cell count
• D. Hemoglobin level

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

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