Nursing Elites

1. A client is receiving heparin therapy. Which of the following laboratory tests should be monitored to evaluate the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Complete blood count (CBC)

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the most appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works on the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps assess its anticoagulant effect. Therapeutic levels of aPTT for clients on heparin therapy are typically 1.5 to 2.5 times the control value. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, which acts on the extrinsic pathway of the coagulation cascade. Complete blood count (CBC) is not specific for monitoring the effectiveness of heparin therapy.

2. The client admitted to the hospital with pulmonary edema is preparing for discharge. The client should be reminded of the importance of complying with which measure to prevent a recurrence?

• A. Weigh oneself every morning before breakfast.
• B. Sleep with the head elevated on multiple pillows.
• C. Adjust diuretic dose without healthcare provider guidance.
• D. Take additional digoxin (Lanoxin) as a preventive measure.

Correct answer: A

Rationale: Monitoring weight daily, especially in the morning before breakfast, is crucial in detecting fluid retention early and preventing pulmonary edema. Sudden weight gain can indicate fluid accumulation, prompting timely intervention to prevent complications. Choice A is the correct answer because daily weight monitoring is a key component in managing heart failure and preventing pulmonary edema recurrence. Choices B and D are not directly related to preventing fluid retention or pulmonary edema recurrence. Choice C is unsafe as adjusting diuretic doses without healthcare provider guidance can lead to electrolyte imbalances and worsening of the condition.

3. The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu?

• A. Tea
• B. Cola
• C. Coffee
• D. Lemonade

Correct answer: D

Rationale: Lemonade is the correct choice as it is caffeine-free, unlike tea, cola, and coffee, which contain caffeine that can potentially affect the client's heart rhythm. Caffeine can increase heart rate and blood pressure, which may not be advisable for a client with a recent MI. Tea, cola, and coffee should be avoided due to their caffeine content, which can have stimulant effects on the heart and may not be beneficial for a client recovering from a myocardial infarction.

4. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

• A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
• B. Turn the client prone to apply pressure on the abdominal wound to help staunch the bleeding.
• C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
• D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Correct answer: C

Rationale: In a client with profuse bleeding from a gunshot wound to the abdomen, maintaining the client in a supine position is essential to manage blood pressure. This position helps in reducing diaphragmatic pressure and allows for proper visualization of the wound, aiding in prompt assessment and intervention to control the bleeding and stabilize the client's condition. Placing the client in a 45-degree Trendelenburg position (Choice A) could worsen the bleeding by increasing intrathoracic pressure and venous return, potentially leading to further hemorrhage. Turning the client prone (Choice B) may not be feasible in this situation and can delay essential interventions. Placing the client on the right side (Choice D) does not address the immediate need to manage the bleeding and stabilize the client's condition.

5. The healthcare professional is assisting in the care of a client diagnosed with deep vein thrombosis (DVT). Which instruction should be reinforced to prevent complications?

• A. Elevate the affected leg using pillows.
• B. Perform leg exercises while sitting.
• C. Wear snug compression stockings.
• D. Avoid applying ice packs to injuries.

Correct answer: A

Rationale: Elevating the affected leg using pillows is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promote venous return, thereby decreasing the risk of complications such as pulmonary embolism. This position aids in improving blood circulation and preventing blood clots from forming or worsening in the affected leg. Performing leg exercises while sitting might increase the risk of dislodging a blood clot. While snug compression stockings are beneficial, the primary focus should be on elevation. Avoiding ice packs on injuries is unrelated to DVT management.

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