Nursing Elites

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

3. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

4. When teaching a client about the use of risperidone, which of the following should be included?

• A. It is an SSRI
• B. Monitor for metabolic syndrome
• C. It has no side effects
• D. It can be taken with alcohol

Correct answer: B

Rationale: The correct answer is B: 'Monitor for metabolic syndrome.' Risperidone is not an SSRI but an atypical antipsychotic. Choice A is incorrect. Choice C is also incorrect as risperidone, like any medication, can have side effects. Choice D is wrong because alcohol consumption should generally be avoided while taking risperidone. Educating clients about monitoring for metabolic syndrome, weight gain, and other potential side effects is crucial in managing their health effectively while on this medication.

5. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

• A. Ventrogluteal
• B. Deltoid
• C. Dorsogluteal
• D. Vastus lateralis

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

Similar Questions