a nurse is caring for a client who is receiving a continuous heparin infusion which of the following laboratory values should the nurse monitor to eva
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

Correct answer: C

Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.

2. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

3. A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?

Correct answer: D

Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.

4. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

5. A nurse is reviewing laboratory results for a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D: Aspartate aminotransferase (AST) 60 units/L. An elevated AST level indicates liver damage, which can be a side effect of methotrexate and should be reported. Elevated white blood cell count (choice A), platelet count (choice B), or normal hemoglobin level (choice C) are not directly related to methotrexate therapy for rheumatoid arthritis.

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