Nursing Elites

1. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip prior to initiating the Coumadin
• B. Check the client’s INR prior to beginning Coumadin
• C. Clarify the order with the health care provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

2. The Army Medical Department has four major functions. Three are prevention, treatment, and evacuation. What is the fourth?

• A. Preparation
• B. Training
• C. Mobilization
• D. Selection

Correct answer: C

Rationale: The correct answer is C, 'Mobilization.' Mobilization is the fourth major function of the Army Medical Department. This involves preparing and organizing medical resources and personnel for deployment during military operations. Choices A, B, and D are incorrect because while they are important aspects in military healthcare, they do not represent the fourth major function of the Army Medical Department as specifically requested in the question.

3. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

• A. A submarine sandwich, potato chips, and diet cola
• B. Four (4) slices of a supreme thin-crust pizza and milk
• C. Smoked turkey sandwich, celery sticks, and unsweetened tea
• D. A roast beef sandwich, fried onion rings, and a cola

Correct answer: C

Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea is a healthier option for someone with Type 2 diabetes mellitus. Turkey is a lean protein source, celery sticks are low in calories and carbs, and unsweetened tea is a better choice than sugary beverages. Choices A, B, and D are incorrect. Choice A includes high-carb and high-sugar items like potato chips and diet cola, which are not ideal for diabetes management. Choice B contains a high-carb pizza and milk, which may not be suitable for controlling blood sugar levels. Choice D includes fried onion rings and cola, which are high in unhealthy fats and sugars, making it a poor choice for a diabetic diet.

4. A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit?

• A. Crying
• B. Self-mutilation
• C. Immobile posturing
• D. Repetitive activities

Correct answer: C

Rationale: In catatonic schizophrenia, clients commonly exhibit immobile posturing, where they may maintain a fixed position for extended periods. This could include holding rigid poses or remaining motionless. Choice A, 'Crying,' is not typically associated with catatonic schizophrenia. Choice B, 'Self-mutilation,' refers to a different behavior seen in some mental health conditions but is not a characteristic feature of catatonic schizophrenia. Choice D, 'Repetitive activities,' does not align with the typical presentation of catatonic schizophrenia, which is characterized by motor abnormalities such as immobility rather than engaging in purposeful repetitive movements.

5. When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?

• A. Elevated blood glucose
• B. Decreased blood pressure
• C. Signs of bleeding
• D. Increased appetite

Correct answer: C

Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.

Similar Questions