a nurse is caring for a client receiving heparin which of the following should the nurse monitor
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

2. A school nurse is providing care for students in an elementary education facility. What intervention by the nurse addresses the primary level of prevention?

Correct answer: B

Rationale: The correct answer is B: Teach students about healthy food choices. Teaching healthy habits like proper nutrition is an example of primary prevention because it aims to prevent disease before it occurs. Choice A, monitoring for signs of illness, is more related to secondary prevention (early detection and treatment). Choice C, administering medication to students with chronic conditions, is a form of tertiary prevention (managing existing conditions to prevent complications). Choice D, monitoring immunization compliance, is also a form of primary prevention but focuses on preventing specific infectious diseases through immunization rather than general health promotion.

3. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

4. A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray?

Correct answer: D

Rationale: The correct answer is D, Tortillas. Clients with celiac disease should avoid gluten, which is often found in tortillas. Cornbread, mashed potatoes, and lentils are gluten-free options, making them safe for individuals with celiac disease. Therefore, the other choices (A, B, and C) do not need to be removed from the meal tray.

5. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?

Correct answer: C

Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.

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