Nursing Elites

1. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

• A. Monitoring blood pressure
• B. Checking the activated partial thromboplastin time (aPTT)
• C. Assessing for signs of bleeding
• D. Measuring calf circumference

Correct answer: C

Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.

2. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

• A. Rifampin
• B. Isoniazid
• C. Acyclovir
• D. Pyrazinamide

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

3. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

• A. Allow family members to remain at the bedside.
• B. Ask the family if the client would like a fan in the room.
• C. Keep the television tuned to the client's favorite channel.
• D. Speak loudly to the client in case of hearing problems.

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

4. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

5. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?

• A. Constant bubbling in the suction-control chamber
• B. Continuous bubbling in the water-seal chamber
• C. Bloody drainage in the collection chamber
• D. Fluid-level fluctuations in the water-seal chamber

Correct answer: B

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.

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