Nursing Elites

1. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

• A. Continue the heparin infusion as prescribed.
• B. Decrease the heparin infusion rate.
• C. Increase the heparin infusion rate.
• D. Stop the heparin infusion and notify the healthcare provider.

Correct answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

2. The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates a need for further teaching?

• A. I will use my albuterol inhaler before exercising.
• B. I will avoid secondhand smoke.
• C. I will get a flu shot every year.
• D. I will limit my fluid intake to 2 liters per day.

Correct answer: A

Rationale: Using an albuterol inhaler before exercising is appropriate for clients with COPD to prevent exercise-induced bronchospasm.

3. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?

• A. Serum sodium of 140 mEq/L.
• B. Serum osmolality of 280 mOsm/kg.
• C. Weight gain of 2 pounds in 24 hours.
• D. Serum sodium of 130 mEq/L.

Correct answer: D

Rationale: The corrected answer is D. A serum sodium level of 130 mEq/L indicates hyponatremia, which requires immediate intervention in a client with SIADH. Hyponatremia can lead to serious complications such as seizures, coma, and cerebral edema. Choices A, B, and C are not the most critical findings in a client with SIADH. While a serum sodium of 140 mEq/L is within the normal range, a decrease to 130 mEq/L is concerning and requires prompt action to prevent complications.

4. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 before administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

• A. Administer the dose as prescribed.
• B. Hold the medication.
• C. Call the healthcare provider.
• D. Repeat the vital signs in 30 minutes.

Correct answer: A

Rationale: The correct action is to administer the dose as prescribed. Verapamil slows sinoatrial nodal automaticity and delays atrioventricular nodal conduction, which helps in slowing the ventricular rate. The heart rate of 92 and blood pressure of 110/76 are within an acceptable range for administering verapamil in a client with atrial flutter. Holding the medication, calling the healthcare provider, or repeating the vital signs in 30 minutes are not necessary based on the vital signs obtained and the action of verapamil in this scenario.

5. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

• A. Call the pharmacy to determine what medications she is taking
• B. Seek the family's assistance in taking care of the client
• C. Complete a physical and mental exam on the client
• D. Call the adult protective services to obtain emergency nursing home placement

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

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