Nursing Elites

1. A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?

• A. Stimulate white blood cell production
• B. Increase platelet count
• C. Promote red blood cell production
• D. Enhance clotting factor production

Correct answer: C

Rationale: Erythropoietin primarily stimulates the bone marrow to produce more red blood cells, which helps to improve oxygen delivery to tissues. In chronic kidney disease, patients often develop anemia due to reduced erythropoietin production by the kidneys. By administering exogenous erythropoietin, the deficient hormone is replaced, leading to an increase in red blood cell production and subsequently improving the oxygen-carrying capacity of the blood.

2. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

3. A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. Bleeding time
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Partial thromboplastin time (PTT). Heparin affects the intrinsic pathway of the coagulation cascade, which is reflected by changes in the PTT. Monitoring the PTT helps ensure that the patient's blood is within the desired therapeutic range and prevents complications related to clotting or bleeding. Prothrombin time (PT) primarily assesses the extrinsic pathway and is not as sensitive to heparin therapy. Bleeding time and platelet count are not specific tests for monitoring the effectiveness of heparin therapy in DVT.

4. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.

5. When teaching a client postoperative breathing techniques with an incentive spirometer (IS), what should the nurse encourage the client to do to maintain sustained maximal inspiration?

• A. Exhale forcefully into the tubing for 3 to 5 seconds.
• B. Inspire deeply and slowly over 3 to 5 seconds.
• C. Breathe into the spirometer using normal breath volumes.
• D. Perform IS breathing exercises every 6 hours.

Correct answer: B

Rationale: To maintain sustained maximal inspiration when using an incentive spirometer, the client should be encouraged to inspire deeply and slowly over 3 to 5 seconds. This technique aids in achieving the goal of sustained maximal inspiration, which is essential for postoperative respiratory recovery.

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