Nursing Elites

1. The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?

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

Correct answer: C

Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.

2. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

3. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?

• A. Obtain a speech therapy consult
• B. Elevate the head of the bed
• C. Check the client's lung sounds
• D. Implement aspiration precautions

Correct answer: B

Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.

4. The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

• A. Monitor daily weights
• B. Limit fluid intake to prevent fluid overload
• C. Report any weight gain of more than 2 pounds in a day
• D. Increase protein intake to promote healing

Correct answer: C

Rationale: The most important information for the nurse to provide a client with chronic kidney disease is to report any weight gain of more than 2 pounds in a day. This is crucial because sudden weight gain can indicate fluid retention, which is a common issue in kidney disease. Monitoring daily weights, as in option A, is important but not as critical as reporting sudden weight gain. Option B, limiting fluid intake, is a general recommendation for kidney disease but not the most important aspect in this scenario. Option D, increasing protein intake, is not appropriate as excessive protein intake can be harmful for clients with kidney disease.

5. The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?

• A. Auscultate the client's breath sounds
• B. Turn the client to the side
• C. Stop the feeding infusion
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.

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