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 client with newly diagnosed type 1 diabetes mellitus is being taught about insulin administration by the nurse. Which statement indicates that the client needs further teaching?

• A. I will inject my insulin into my abdomen for the fastest absorption.
• B. I will rotate injection sites to prevent lipodystrophy.
• C. I will store my insulin in the refrigerator at all times.
• D. I will rotate injection sites to prevent lipodystrophy.

Correct answer: C

Rationale: The correct answer is C. Insulin should not be stored in the refrigerator at all times; it should be kept at room temperature when in use to avoid irritation at the injection site. Storing insulin in the refrigerator can cause it to thicken and may lead to discomfort upon injection. Choices A and D are correct statements as injecting insulin into the abdomen for faster absorption and rotating injection sites to prevent lipodystrophy are appropriate insulin administration techniques. Therefore, the client does not need further teaching on these aspects.

3. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?

• A. I am very anxious about the surgery.
• B. I drank a glass of juice after midnight.
• C. I have an allergy to latex.
• D. I had nausea after my last surgery.

Correct answer: B

Rationale: The correct answer is B. The client's statement of drinking juice after midnight should be reported to the healthcare provider. Consuming liquids after midnight can increase the risk of aspiration during surgery under general anesthesia. Choices A, C, and D are not as critical to report for the client's safety during the surgical procedure. Anxiety about surgery, latex allergy, and postoperative nausea, although important for overall care, do not pose immediate risks during the surgical preparation as the intake of fluids does.

4. A client with a history of diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which finding requires immediate intervention?

• A. Blood glucose of 200 mg/dL.
• B. Serum bicarbonate of 20 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Urine output of 50 mL in 4 hours.

Correct answer: D

Rationale: In a client with diabetic ketoacidosis (DKA), urine output of 50 mL in 4 hours indicates oliguria, which is a concerning sign of decreased renal perfusion and potential renal failure. This finding requires immediate intervention to prevent further deterioration of kidney function.\n\nChoice A (Blood glucose of 200 mg/dL) is elevated but not the most urgent concern in this scenario. Choice B (Serum bicarbonate of 20 mEq/L) reflects metabolic acidosis, which is expected in DKA but does not require immediate intervention. Choice C (Blood pressure of 140/90 mm Hg) is slightly elevated but not acutely concerning in the context of DKA.

5. A client with a history of alcohol abuse is admitted with cirrhosis. Which finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: C

Rationale: Peripheral edema in a client with cirrhosis can indicate fluid overload and worsening liver function, necessitating immediate intervention to prevent further complications such as respiratory distress, cardiac issues, or renal impairment. Jaundice (choice A) is a common manifestation of cirrhosis but may not require immediate intervention unless severe. Ascites (choice B) is also a common complication of cirrhosis that may require intervention but is not as urgent as addressing peripheral edema. Spider angiomas (choice D) are typically benign skin lesions associated with cirrhosis but do not require immediate intervention unless bleeding or rupture occurs.

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