Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

2. The nurse is caring for a client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention is most important for the nurse to implement?

• A. Encourage oral hydration
• B. Monitor for signs of dehydration
• C. Restrict fluid intake
• D. Administer IV fluids as prescribed

Correct answer: C

Rationale: In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia. The most crucial intervention is to restrict fluid intake to prevent further fluid overload and worsening of hyponatremia. Encouraging oral hydration (choice A) would exacerbate the condition by adding more fluids. Monitoring for signs of dehydration (choice B) is not appropriate as the client is at risk of fluid overload. Administering IV fluids (choice D) would worsen the hyponatremia and should be avoided.

3. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning, she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Client's current mood and affect
• B. When the client last took medications for bipolar disorder
• C. History of previous suicide attempts
• D. Details of the medications ingested

Correct answer: D

Rationale: Determining the specific medications ingested is the priority for guiding immediate treatment in the Emergency Department. Knowing when the client last took medications and her current mood are also important, but the ingested medications are the most urgent information needed. The client's current mood and affect are crucial for assessing her immediate state, but the priority is to identify the substances she ingested to provide appropriate interventions. While understanding the history of previous suicide attempts is relevant for assessing the client's risk, the immediate focus should be on the medications taken during this specific incident.

4. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

• A. Reports of leg cramping at rest
• B. Family history of heart disease
• C. Current use of beta-blockers
• D. History of intermittent claudication

Correct answer: D

Rationale: Corrected Rationale: Intermittent claudication, or pain in the legs while walking that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Other factors such as a family history or medication use may contribute to cardiovascular health, but claudication is the most specific indicator. Leg cramping at rest is more indicative of conditions like peripheral neuropathy or deep vein thrombosis. Family history of heart disease and current use of beta-blockers are relevant to overall cardiovascular health, but they are not as directly related to chronic peripheral arterial insufficiency as intermittent claudication.

5. The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?

• A. Administer pre-transfusion medication
• B. Ensure the client has an adequate fluid intake
• C. Monitor the client's vital signs
• D. Verify the blood type with another nurse

Correct answer: D

Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.

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