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 healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

• A. Blood pressure of 160/90 mm Hg.
• B. Blood glucose level of 180 mg/dL.
• C. Difficulty speaking.
• D. Temperature of 99.8°F (37.7°C).

Correct answer: C

Rationale: Difficulty speaking is a classic symptom of a stroke, indicating a potential blockage of blood flow to the brain. Immediate intervention is crucial to minimize brain damage. While an elevated blood pressure (Choice A) may need management, it is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) falls within the normal range and is not a critical finding in this context.

3. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

4. The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important for the community?

• A. family planning center
• B. accessibility to trauma care
• C. annual health fair
• D. weather-related disaster plan

Correct answer: B

Rationale: In rural areas, accessibility to trauma care is the most critical healthcare resource due to the longer emergency response times. Trauma care can be life-saving in situations where immediate medical attention is required for severe injuries. The other options, such as a family planning center, annual health fair, and weather-related disaster plan, are important but not as crucial as trauma care in addressing urgent health needs in a rural community.

5. A community health nurse is conducting a needs assessment in a rural area. Which data source is most likely to provide comprehensive information about the community's health status?

• A. Focus groups with community members
• B. Local hospital admission records
• C. State health department reports
• D. Surveys conducted by healthcare providers

Correct answer: C

Rationale: State health department reports are the most likely data source to provide comprehensive information about the community's health status. These reports offer a broad overview of health statistics and trends that can guide community health interventions. Focus groups with community members, although valuable for gathering qualitative insights, may not provide comprehensive health status data. Local hospital admission records are limited to specific healthcare utilization data and do not capture the overall health status of the entire community. Surveys conducted by healthcare providers may offer some insights but may not provide the breadth and depth of information available in state health department reports.

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