Nursing Elites

1. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Platelet count

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.

2. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

3. A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.

4. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

5. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote oxygenation by improving lung expansion
• C. To encourage use of accessory muscles for breathing
• D. To drain secretions and prevent aspiration

Correct answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

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