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. A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?

• A. Increased white blood cell count
• B. Crackles heard on lung auscultation
• C. Productive cough with green sputum
• D. Decreased respiratory rate from 24 to 18 breaths per minute

Correct answer: D

Rationale: A decrease in respiratory rate indicates that the client's breathing is becoming more stable, which suggests an improvement in their condition. Respiratory rate is a critical indicator of respiratory status and oxygenation. Increased white blood cell count (choice A) suggests ongoing infection, crackles on lung auscultation (choice B) indicate fluid in the lungs, and productive cough with green sputum (choice C) may indicate persistent infection or airway inflammation, which do not necessarily reflect improvement in pneumonia.

3. The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?

• A. Flush the tube with water every 4 hours
• B. Check the tube placement before each feeding
• C. Secure the tube to the client's nose with tape
• D. Keep the head of the bed elevated at 30 degrees

Correct answer: B

Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.

4. A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?

• A. Encourage discussion of feelings about the loss of his limb.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer to assist the client to a quieter location to relax.

Correct answer: B

Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.

5. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states 'I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.' The nurse should understand that

• A. A referral is needed to the psychiatrist who is to provide the client with answers
• B. The client has a right to know about the prescribed medications
• C. Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
• D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Correct answer: B

Rationale: The correct answer is B. The client has a legal right to be informed about their treatment, including medication uses and side effects, as part of informed consent. This helps ensure that the client can make an informed decision about their care. Choice A is incorrect because the nurse can provide the client with information about their medications. Choice C is incorrect as it is not an independent decision of the nurse but a professional responsibility to educate clients. Choice D is incorrect as knowledge about medication side effects can actually empower clients to manage their condition effectively.

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