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. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

3. A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?

• A. Nausea and vomiting.
• B. Altered consciousness within the first 24 hours after injury.
• C. Severe headache and blurred vision.
• D. Loss of motor function on the affected side.

Correct answer: B

Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.

4. The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

• A. Assessing the client's ability to ambulate safely
• B. Documenting the client's tolerance of ambulation
• C. Assisting the client with ambulation
• D. Evaluating the client's pain level after ambulation

Correct answer: C

Rationale: Assisting with ambulation is a task that can be safely delegated to a UAP as it is a supportive activity that does not require clinical judgment. Choices A, B, and D involve assessments, documentation, and evaluation, which require nursing knowledge and clinical judgment, making them tasks that should be performed by a licensed nurse.

5. The nurse is providing care for a client receiving total parenteral nutrition (TPN). Which action should the nurse include in the client's plan of care?

• A. Increase the TPN infusion rate if the client is hungry
• B. Administer TPN via a peripheral IV line
• C. Monitor blood glucose levels regularly
• D. Ensure the TPN solution is refrigerated at all times

Correct answer: C

Rationale: The correct action the nurse should include in the client's plan of care is to monitor blood glucose levels regularly. Clients receiving TPN are at risk for hyperglycemia due to the high glucose content of the solution. Regular monitoring of blood glucose levels is essential to ensure appropriate management of blood sugar. Choice A is incorrect because increasing the TPN infusion rate based on hunger is not a valid parameter for adjusting TPN. Choice B is incorrect because TPN should be administered through a central line, not a peripheral IV line, to prevent complications. Choice D is incorrect because TPN solutions should be stored at room temperature, not refrigerated.

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