Nursing Elites

1. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a private room with negative airflow.
• B. Wear an N95 respirator when caring for the client.
• C. Place the client in a positive pressure room.
• D. Maintain the client on droplet precautions.

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

2. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

3. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?

• A. Creatinine.
• B. Aspartate aminotransferase (AST).
• C. White blood cell count.
• D. Serum glucose.

Correct answer: A

Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.

4. Which of the following lab values indicates a patient on warfarin is at a therapeutic level?

• A. INR of 1.1
• B. PT of 12 seconds
• C. INR of 2.5
• D. Platelet count of 150,000

Correct answer: C

Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.

5. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?

• A. Prothrombin time (PT)
• B. International Normalized Ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.

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