Nursing Elites

1. A client with deep vein thrombosis (DVT) is prescribed heparin. What lab value should the nurse monitor to assess the effectiveness of the therapy?

• A. Prothrombin time (PT).
• B. Partial thromboplastin time (PTT).
• C. International Normalized Ratio (INR).
• D. Hemoglobin and hematocrit.

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is the lab value used to monitor the effectiveness of heparin therapy in clients with DVT. It measures the intrinsic pathway of coagulation and is prolonged by heparin therapy. Prothrombin time (PT) and International Normalized Ratio (INR) are primarily used to monitor warfarin therapy, not heparin. Checking hemoglobin and hematocrit levels is important but does not directly assess the effectiveness of heparin therapy in DVT.

2. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

• A. Potassium level of 4.0 mEq/L.
• B. Blood glucose level of 180 mg/dL.
• C. Urine output of 50 mL/hour.
• D. Absence of ketones in the urine.

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

3. A client with chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. What teaching should the nurse provide?

• A. Ensure that the client uses oxygen continuously at night.
• B. Instruct the client to avoid smoking and exposure to smoke.
• C. Teach the client how to clean and replace the oxygen tubing.
• D. Instruct the client to increase their fluid intake.

Correct answer: C

Rationale: The correct teaching for a client with COPD prescribed home oxygen therapy is to educate them on how to clean and replace the oxygen tubing. This is crucial to prevent infections and ensure the effectiveness of the oxygen delivery system. Option A is not necessary as oxygen therapy is usually prescribed as needed, not continuously at night. While smoking cessation and avoiding smoke exposure are important in COPD management, it is not directly related to home oxygen therapy. Increasing fluid intake is beneficial for some conditions but is not specifically related to home oxygen therapy for COPD.

4. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?

• A. Encourage the client to rest and limit activity.
• B. Administer a beta-blocker to reduce heart rate.
• C. Encourage the client to drink cool fluids.
• D. Provide the client with a cool environment.

Correct answer: B

Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.

5. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: The correct action for the nurse to take when a client develops urticaria during a blood transfusion is to immediately stop the infusion. Urticaria is a sign of a transfusion reaction, and stopping the infusion is crucial to prevent the reaction from worsening. Slowing the rate of infusion (Choice B) is not appropriate in this situation as the reaction has already started. While taking vital signs and observing for further deterioration (Choice C) is important, the priority is to stop the transfusion. Administering Benadryl and continuing the infusion (Choice D) is not recommended until the client's condition has stabilized and healthcare provider orders have been obtained.

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