Nursing Elites

1. Which lab value is critical for monitoring warfarin therapy?

• A. Monitor INR
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

2. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Apply heat to the incision site.
• B. Keep the client's knee flexed while in bed.
• C. Place a pillow under the client's knee while in bed.
• D. Place a pillow under the client's lower legs.

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

3. What is the most appropriate action when a patient experiences a fall in the hospital?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to assess the patient for injuries. When a patient experiences a fall in the hospital, the immediate concern is to check for any injuries that may require urgent care. Calling for help can be done after assessing the patient to ensure appropriate assistance is provided. Documenting the fall is important for the patient's medical record, but it is not the most immediate action needed. Notifying the healthcare provider can come after the initial assessment to update them on the situation.

4. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following sites should the healthcare provider select?

• A. Deltoid
• B. Vastus lateralis
• C. Rectus femoris
• D. Dorsogluteal

Correct answer: B

Rationale: The vastus lateralis is the preferred site for intramuscular injections in adults due to its large muscle mass and low risk of complications. The deltoid, although a common site for vaccines, has a smaller muscle mass and may not be suitable for all types of medications. The rectus femoris is a muscle in the thigh that is more commonly used for intramuscular injections in infants. The dorsogluteal site is no longer recommended due to its proximity to major nerves and blood vessels.

5. How should a healthcare provider manage a patient with chronic heart failure?

• A. Monitor daily weight
• B. Provide fluid restriction
• C. Administer diuretics
• D. Monitor intake and output

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.

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