Nursing Elites

1. A client is receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

• A. Slow the infusion and continue to monitor the site
• B. Stop the infusion
• C. Apply a warm compress to the site
• D. Apply a cold compress to the site

Correct answer: B

Rationale: When an IV site appears infiltrated, it indicates that the medication is leaking into the surrounding tissues. In such a situation, the infusion should be stopped immediately to prevent further tissue damage. Choice A is incorrect because slowing the infusion would still allow the medication to leak into the tissues. Choices C and D are also incorrect as applying compresses can exacerbate the tissue damage caused by infiltration.

2. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

3. A nurse is preparing to administer metoprolol to a client with hypertension. Which of the following should the nurse assess prior to administering this medication?

• A. Temperature
• B. Heart rate
• C. Respiratory rate
• D. Blood pressure

Correct answer: D

Rationale: The correct answer is D: Blood pressure. Before administering metoprolol, a beta-blocker commonly used to treat hypertension, the nurse should assess the client's blood pressure. Metoprolol works by lowering blood pressure and reducing the workload on the heart. Assessing the blood pressure is crucial to ensure it is within the acceptable range to administer the medication safely. Choices A, B, and C (Temperature, Heart rate, Respiratory rate) are important assessments in general patient care but are not specifically required before administering metoprolol for hypertension.

4. When administering amlodipine to a client with hypertension, what adverse effect should the nurse monitor for?

• A. Constipation
• B. Facial flushing
• C. Hypotension
• D. Jaundice

Correct answer: C

Rationale: The correct answer is C, Hypotension. Amlodipine is a calcium channel blocker commonly used to treat hypertension. One of the main adverse effects of amlodipine is hypotension, leading to low blood pressure. The nurse should monitor the client for signs of hypotension such as dizziness, lightheadedness, or fainting. Choices A, B, and D are incorrect because constipation, facial flushing, and jaundice are not typically associated with amlodipine administration.

5. A healthcare provider is preparing to administer heparin sodium to a client with deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor during therapy?

• A. INR
• B. Serum creatinine
• C. aPTT
• D. Bilirubin

Correct answer: C

Rationale: The correct answer is C: aPTT. The healthcare provider should monitor the activated partial thromboplastin time (aPTT) value during heparin therapy to assess the client's coagulation status. Heparin affects the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps ensure that the client is within the therapeutic range to prevent bleeding or clotting issues. INR (Choice A) is used to monitor warfarin therapy, not heparin. Serum creatinine (Choice B) is not directly related to monitoring heparin therapy. Bilirubin (Choice D) is related to liver function, not heparin therapy.

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