Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?

• A. Monitor for signs of bleeding, such as bruising.
• B. Monitor the client’s vital signs every hour.
• C. Monitor for pain in the affected limb.
• D. Assess for signs of pulmonary embolism, such as sudden shortness of breath.

Correct answer: D

Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.

2. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

• A. Hemoglobin level
• B. Platelet count
• C. Activated partial thromboplastin time (aPTT)
• D. Prothrombin time (PT)

Correct answer: B

Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.

3. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

4. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?

• A. Stop the feeding and provide IV fluids.
• B. Dilute the feeding to half strength and continue at the same rate.
• C. Reduce the feeding rate and monitor for improvement.
• D. Add fiber to the client's diet to resolve diarrhea.

Correct answer: B

Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.

5. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

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