Nursing Elites

1. 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.

2. A nurse is assessing a client who has a history of gastroesophageal reflux disease (GERD). Which of the following findings should the nurse identify as a complication of GERD?

• A. Hematemesis.
• B. Melena.
• C. Pallor.
• D. Steatorrhea.

Correct answer: A

Rationale: The correct answer is A: Hematemesis. Hematemesis (vomiting blood) is a sign of gastrointestinal bleeding and a serious complication of GERD. Melena (black, tarry stool) is also a sign of GI bleeding but is not as specific to GERD as hematemesis. Pallor may be present due to anemia from chronic blood loss, but it is not a direct complication of GERD. Steatorrhea is not typically associated with GERD; it is more indicative of malabsorption issues.

3. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

• A. Prime the IV tubing with 0.9% sodium chloride.
• B. Verify the client's blood type and Rh factor.
• C. Administer the blood over 8 hours.
• D. Use a 22-gauge needle for venous access.

Correct answer: B

Rationale: The correct answer is to verify the client's blood type and Rh factor. This action is crucial to ensure that the correct blood is administered, matching the client's blood type and Rh factor, which helps prevent transfusion reactions. Priming the IV tubing with 0.9% sodium chloride (Choice A) is not directly related to ensuring the correct blood product is administered. Administering the blood over 8 hours (Choice C) is not the standard practice for packed RBCs, which are usually given over a shorter period. Using a 22-gauge needle for venous access (Choice D) is not specific to the preparation for administering packed RBCs.

4. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.

5. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left lower extremity. Which of the following findings should the nurse expect?

• A. Pain in the right lower extremity
• B. Cold skin in the affected extremity
• C. Redness and warmth in the affected extremity
• D. Shiny skin on the affected extremity

Correct answer: C

Rationale: Corrected Rationale: Redness and warmth are classic signs of inflammation, which are commonly seen in clients with deep vein thrombosis (DVT). These findings indicate increased blood flow and temperature in the affected area. Pain in the right lower extremity (Choice A) is not expected in a client with DVT affecting the left lower extremity. Cold skin (Choice B) is not a typical finding in DVT; instead, warmth is more indicative of inflammation. Shiny skin (Choice D) is not a common characteristic of DVT; rather, the skin may appear red, swollen, and warm due to the inflammatory process.

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