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 unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair.
• B. The assistant inserted two (2) fingers under the proximal end of the stocking.
• C. The assistant elevated the feet while lying down to put on the stockings.
• D. The assistant made sure the toes were warm after putting the stockings on.

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

3. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the Clinitest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, it is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading. Choice A is incorrect as the specimen should be collected before meals for accurate results. Choice B is incorrect as it should be the Clinitest tablet, not the clingiest tablet. Choice D is incorrect as the statement is incomplete and lacks clarity.

4. The client diagnosed with Type 2 diabetes mellitus is being taught about diet by the nurse. 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 reflects a balanced and healthy choice suitable for a client with Type 2 diabetes mellitus. Turkey is a lean protein choice, celery sticks offer fiber and low calories, and unsweetened tea is a sugar-free beverage. Choices A, B, and D are incorrect as they include high-carb, high-fat, and sugary options that are not recommended for individuals with diabetes as they can spike blood sugar levels.

5. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

• A. The nurse repeats the information as indicated by the client’s questions
• B. The nurse teaches all the information needed by the client in one session
• C. The nurse uses a video to explain medical terms to the client
• D. The nurse waits until the client asks questions about the surgery

Correct answer: A

Rationale: Choice A is the correct answer because repeating information and addressing the client’s questions as they arise is an effective method for reinforcing learning in adults. This approach allows for immediate clarification and reinforcement of important points. Choice B is incorrect because teaching all the information in one session may be overwhelming for the client and hinder retention. Choice C is incorrect as using a video with medical terms may not necessarily address the client's specific questions or concerns. Choice D is also incorrect because waiting for the client to ask questions may lead to missed opportunities for providing crucial information and addressing uncertainties.

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