Nursing Elites

1. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?

• A. Bleeding time
• B. Platelet count
• C. Activated PTT
• D. Clotting time

Correct answer: C

Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.

2. When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?

• A. Blood pressure of 90/60 mm Hg
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Urine output of 30 mL per hour

Correct answer: A

Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.

3. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

4. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

5. When speaking with a group of teens, which side effect of chemotherapy for cancer would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Hair loss is the correct answer. Teens are often more concerned about hair loss because of its visible impact and social implications. While mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, hair loss tends to be a significant concern for teens due to its effect on self-image and confidence.

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