Nursing Elites

1. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?

• A. INR of 1.5
• B. Platelet count of 200,000/mm³
• C. Hemoglobin of 12 g/dL
• D. aPTT of 70 seconds

Correct answer: A

Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.

2. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

3. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

• A. 'I can see that this is upsetting you.'
• B. 'It is necessary for your treatment.'
• C. 'It will be over quickly, and you will feel better.'
• D. 'Let me explain again why this procedure is important.'

Correct answer: A

Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.

4. A healthcare provider is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the healthcare provider include?

• A. Obtain a tetanus booster every 5 years.
• B. Obtain a herpes zoster immunization by age 50.
• C. Have a dental examination every 6 months.
• D. Have a testicular examination every 2 years.

Correct answer: C

Rationale: Having a dental examination every 6 months is crucial for young adult males as it helps in maintaining good oral health and detecting any potential issues early on. Tetanus booster every 10 years is recommended for adults, not every 5 years (Choice A). Herpes zoster immunization is typically recommended for individuals aged 60 and older, not by age 50 (Choice B). While testicular self-examination is important for detecting testicular cancer, routine clinical testicular examinations are not generally needed every 2 years (Choice D). Therefore, the correct answer is to have a dental examination every 6 months.

5. A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:

• A. Limit milk and milk products
• B. Encourage bed rest and quiet activities
• C. Plan nursing care around lengthy rest periods
• D. Promote a diet rich in iron

Correct answer: C

Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.

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