Nursing Elites

1. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

2. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

• A. Monitor the client’s vital signs every hour.
• B. Assess for changes in the client’s muscle strength.
• C. Administer prescribed corticosteroids to reduce inflammation.
• D. Educate the client on managing fatigue and preventing relapses.

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

3. The nurse is providing discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I will use a raised toilet seat to prevent bending too far.
• C. I should keep my legs together to prevent dislocation.
• D. I will use a walker when moving around initially.

Correct answer: C

Rationale: The correct answer is C. Clients who have had a hip replacement should not keep their legs together to prevent dislocation. This position increases the risk of hip dislocation. Choices A, B, and D are correct statements. Avoiding crossing legs, using a raised toilet seat to prevent excessive bending, and using a walker when moving around initially are all appropriate measures to ensure proper recovery and prevent complications after a total hip replacement.

4. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

5. 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.

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