a nurse is caring for a client receiving heparin which of the following should the nurse monitor 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. What are the signs of opioid withdrawal, and how should it be managed?

Correct answer: A

Rationale: The signs of opioid withdrawal typically include sweating and nausea. The correct management approach involves administering methadone to alleviate the symptoms. Choice B is incorrect because naloxone is used to reverse opioid overdose, not for managing withdrawal symptoms. Choice C is incorrect as buprenorphine is typically used to treat opioid addiction, not just withdrawal symptoms. Choice D is incorrect as sedatives are not the primary treatment for opioid withdrawal.

3. When transitioning from a long-term care facility to an acute care facility, what does the nurse need to do?

Correct answer: A

Rationale: When transitioning from a long-term care facility to an acute care facility, the nurse needs to adapt motivational approaches. The environment and patient needs change significantly between these settings. Adapting motivational approaches is crucial to effectively meet the demands of the new job and provide optimal care in the acute care setting. This adjustment allows the nurse to cater to the different needs and pace of care required in an acute care facility compared to a long-term care facility. Choices B, C, and D are incorrect as they do not address the specific need for adapting motivational approaches when transitioning between these types of healthcare facilities.

4. What types of muscular movement occur in the intestine?

Correct answer: A

Rationale: The correct answer is A: Longitudinal and circular. Longitudinal and circular muscles are responsible for the movements that help propel food through the intestine. Choice B, expulsion and traction, is incorrect as these terms do not specifically relate to the types of muscular movement in the intestine. Choice C, tonus and clonus, refers to different types of muscle contractions and are not the primary movements in the intestine. Choice D, intermittent and continuous, does not accurately describe the specific types of muscular movement that occur in the intestine.

5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: “When the cat’s away, the mice will play.” The client responds, “The mice come out when the cat is not around.” The nurse should document this finding as:

Correct answer: D

Rationale: The client’s literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.

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