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 female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

3. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

4. A client undergoing chemotherapy reports extreme fatigue. What should the nurse recommend to manage this symptom?

• A. Increase the dose of chemotherapy.
• B. Rest when needed and maintain a balanced diet.
• C. Perform light physical activity to reduce fatigue.
• D. Consider delaying the chemotherapy treatment.

Correct answer: B

Rationale: The correct recommendation for managing chemotherapy-induced fatigue is to advise the client to rest when needed and maintain a balanced diet. Increasing the dose of chemotherapy (Choice A) would exacerbate the fatigue and other side effects. While light physical activity (Choice C) can be beneficial, extreme fatigue may require more rest initially. Delaying chemotherapy treatment (Choice D) should only be considered after consultation with the healthcare provider, as timely treatment is usually crucial in cancer care.

5. A client with chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Notify the healthcare provider immediately.
• C. Position the client in high Fowler's position.
• D. Suction the client's airway.

Correct answer: A

Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.

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