Nursing Elites

1. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?

• A. INR 2.0
• B. Platelet count 150,000/mm3
• C. aPTT 60 seconds
• D. WBC count 8,000/mm3

Correct answer: C

Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.

2. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

3. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

4. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following instructions should the nurse include?

• A. Take this medication in the morning.
• B. You may experience a persistent cough while taking this medication.
• C. Avoid taking this medication with a potassium supplement.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct answer is B: 'You may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. It is essential for the nurse to educate the client about this potential side effect, as it should be reported to the healthcare provider. Choice A is incorrect because lisinopril is usually taken once daily, but not necessarily at bedtime. Choice C is incorrect because lisinopril can actually increase potassium levels, so taking it with a potassium supplement may lead to hyperkalemia. Choice D is incorrect because antacids may reduce the effectiveness of lisinopril, so it should not be taken with them.

5. A client has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Avoid taking antacids at the same time as this medication.
• C. Take this medication if your heart rate is above 100/min.
• D. Notify your provider if you experience nausea or visual changes.

Correct answer: D

Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.

Similar Questions