Nursing Elites

1. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?

• A. Monitor for renal failure.
• B. Monitor psychosocial status.
• C. Monitor for signs of bleeding.
• D. Have heparin sodium available.

Correct answer: C

Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.

2. The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?

• A. Clotting time
• B. Uric acid level
• C. Potassium level
• D. Blood glucose level

Correct answer: B

Rationale: The correct answer is B, Uric acid level. Busulfan can cause an increase in uric acid levels, leading to hyperuricemia, renal stones, and acute renal failure. Monitoring uric acid levels is crucial to detect and manage potential complications associated with busulfan therapy.

3. Heparin sodium is prescribed for the client. The nurse expects that the healthcare provider will prescribe which of the following to monitor for a therapeutic effect of the medication?

• A. Hematocrit level
• B. Hemoglobin level
• C. Prothrombin time (PT)
• D. Activated partial thromboplastin time (aPTT)

Correct answer: D

Rationale: The correct answer is D, activated partial thromboplastin time (aPTT). Heparin affects the intrinsic pathway of coagulation. Monitoring aPTT helps ensure that heparin sodium is within the therapeutic range to prevent clot formation. Hematocrit and hemoglobin levels assess red blood cell concentrations and are not specific to monitoring heparin therapy. Prothrombin time (PT) is used to monitor the therapeutic effect of warfarin sodium, which affects the extrinsic pathway of coagulation, not heparin.

4. Which laboratory test should the nurse monitor to determine the effectiveness of heparin therapy for a client with deep vein thrombosis?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Activated partial thromboplastin time (aPTT)
• D. Hemoglobin and hematocrit

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the specific laboratory test used to monitor the effectiveness of heparin therapy in patients with deep vein thrombosis. It measures the time it takes for blood to clot and is crucial in assessing the therapeutic range of heparin. Platelet count, prothrombin time (PT), and hemoglobin and hematocrit levels are important parameters in assessing coagulation and blood status but do not directly indicate the effectiveness of heparin therapy.

5. After administering acetylcysteine (Mucomyst), 20% solution diluted in 0.9% normal saline by nebulizer, the nurse should have which item available for potential use?

• A. Ambu bag
• B. Intubation tray
• C. Nasogastric tube
• D. Suction equipment

Correct answer: D

Rationale: Acetylcysteine is administered via inhalation as a mucolytic. It helps liquefy secretions, making it easier for the client to clear them. However, in some cases, the increased volume of liquefied secretions may be challenging for the client to manage, leading to the potential need for suction equipment to assist in clearing the airway. Therefore, the nurse should have suction equipment available after administering acetylcysteine to address any issues related to excessive secretions.

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