Nursing Elites

1. The nurse is caring for a client taking warfarin. Which meal brought in by the client's family is a priority to remove before the client eats it?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct answer is C. Ham is high in vitamin K, which can interfere with warfarin. Vitamin K can decrease the effectiveness of warfarin, an anticoagulant medication. Choices A, B, and D do not contain high levels of vitamin K and are less likely to interfere with the client's warfarin therapy.

2. What gastrointestinal side effects are associated with antisecretory drugs such as proton pump inhibitors?

• A. Nausea and vomiting
• B. Gastroparesis
• C. Dumping syndrome
• D. Flatulence

Correct answer: A

Rationale: Proton pump inhibitors (PPIs) are a type of antisecretory drug that can cause nausea and vomiting by altering stomach acid production. These are common side effects associated with PPIs. Gastroparesis (B) is a condition that affects the stomach muscles and prevents proper stomach emptying; it is not a side effect of PPIs. Dumping syndrome (C) is a group of symptoms that can occur after having part of your stomach removed and is not a side effect of PPIs. While some people might experience flatulence (D) when taking PPIs, it is not as commonly associated with these drugs as the effects of nausea and vomiting.

3. A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?

• A. Administer enteral feedings
• B. Limit intake of vitamin C
• C. Limit dietary protein
• D. Administer insulin prior to meals

Correct answer: A

Rationale: Administering enteral feedings is crucial for ensuring adequate nutrition and supporting healing in toddlers with extensive burns. Burns over 50% total body surface area can lead to increased metabolic demands, making it essential to provide nutrition through enteral feedings to meet the child's needs for healing and recovery. Limiting intake of vitamin C or dietary protein would be detrimental in this scenario as the child requires increased amounts of nutrients to support healing. Administering insulin prior to meals is not indicated in this case as the priority is to provide adequate nutrition to promote healing.

4. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

5. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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