Nursing Elites

1. A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?

• A. Platelet count
• B. Partial thromboplastin time (PTT)
• C. Prothrombin time (PT)
• D. Bleeding time

Correct answer: B

Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

3. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

4. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take the medication with milk
• B. Take with a glass of orange juice
• C. Take at bedtime
• D. Take with meals

Correct answer: B

Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.

5. A nurse is teaching a client with mild persistent asthma who has been prescribed montelukast. Which statement by the nurse is appropriate?

• A. This medication can be used during an acute asthma attack.
• B. This medication should be taken before exercise.
• C. You can take this medication for 10 days, then discontinue.
• D. This medication helps decrease swelling and mucus production.

Correct answer: D

Rationale: The correct answer is D: 'This medication helps decrease swelling and mucus production.' Montelukast is used for long-term asthma management as it helps reduce inflammation and mucus production in the airways. It is not appropriate for acute asthma attacks. Choice A is incorrect because montelukast is not a rescue medication for acute attacks. Choice B is incorrect because montelukast is not specifically taken before exercise. Choice C is incorrect because montelukast is usually taken regularly, not just for a short duration.

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