Nursing Elites

1. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

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

Correct answer: B

Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.

2. A nurse finds a pregnant client at 33 weeks gestation in cardiac arrest. What modification to cardiopulmonary resuscitation (CPR) should the nurse implement?

• A. Administer chest compressions at a faster rate.
• B. Position a firm wedge under the client’s pelvis and thorax at a 30-degree tilt.
• C. Position the client flat with legs elevated.
• D. Call for immediate assistance and prepare for a cesarean section.

Correct answer: B

Rationale: In a pregnant client at 33 weeks gestation, performing CPR requires tilting the pelvis and thorax at a 30-degree angle to relieve pressure on the vena cava, ensuring proper circulation during compressions. Administering chest compressions at a faster rate (Choice A) may not address the specific needs of a pregnant client in cardiac arrest. Positioning the client flat with legs elevated (Choice C) is not recommended as it can worsen vena cava compression. Calling for immediate assistance and preparing for a cesarean section (Choice D) should be considered only after initiating appropriate CPR modifications.

3. A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?

• A. Avoid eating foods high in potassium.
• B. Avoid foods high in vitamin K.
• C. Take the medication on an empty stomach.
• D. Take the medication at bedtime for best results.

Correct answer: B

Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.

4. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity that includes physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.

5. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?

• A. Improved tolerance to cold.
• B. Decreased fatigue and improved energy levels.
• C. Reduced anxiety and improved mood.
• D. Increased sensitivity to heat.

Correct answer: B

Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.

Similar Questions