Nursing Elites

1. When should the charge nurse intervene based on the observed behavior?

• A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
• B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
• C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
• D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

2. A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?

• A. Increase in blood pressure
• B. Frank red bleeding from the surgical site
• C. Clear drainage from the surgical wound
• D. Decrease in heart rate

Correct answer: B

Rationale: Frank red bleeding from the surgical site is a significant sign of hemorrhage that warrants immediate attention. It indicates active bleeding that needs to be addressed promptly to prevent further complications.

3. A client with liver failure is at an increased risk of bleeding due to the inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

• A. Alterations in glucose metabolism
• B. Retention of bile salts
• C. Inadequate production of albumin by hepatocytes
• D. Inability of the liver to use vitamin K

Correct answer: D

Rationale: The correct answer is D. The liver's inability to use vitamin K is the most likely factor contributing to the loss of prothrombin synthesis in liver failure. Vitamin K is essential for the synthesis of prothrombin, a crucial clotting factor. In liver failure, impaired utilization of vitamin K leads to decreased production of prothrombin, increasing the risk of bleeding in affected individuals.

4. The client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications by the nurse. Which instruction should the nurse include?

• A. Increase your intake of spicy foods.
• B. Avoid lying down immediately after eating.
• C. Consume a high-fat diet.
• D. Drink caffeinated beverages with meals.

Correct answer: B

Rationale: Avoiding lying down immediately after eating is essential in managing GERD as it helps prevent reflux symptoms by allowing gravity to assist in keeping stomach contents down. Lying down can worsen symptoms by allowing acid to flow back into the esophagus.

5. 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.

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