Nursing Elites

1. The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.

2. A client is prescribed warfarin (Coumadin) for atrial fibrillation. Which dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Avoid foods high in vitamin K
• C. Increase intake of foods rich in vitamin C
• D. Limit intake of dairy products

Correct answer: B

Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Vitamin K can decrease the effectiveness of warfarin, so it is essential for clients on warfarin therapy to avoid foods high in vitamin K. Green leafy vegetables are high in vitamin K, so choice A is incorrect. Choices C and D are unrelated to the dietary restrictions needed for clients taking warfarin and are therefore incorrect.

3. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?

• A. 15 mL
• B. 10 mL
• C. 20 mL
• D. 5 mL

Correct answer: A

Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.

4. A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?

• A. Starting an exercise program
• B. Keeping a sleep diary
• C. Practicing relaxation techniques before bed
• D. Using sleep-inducing medications at night

Correct answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

5. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

Similar Questions