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. Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?

• A. Wear long-sleeved clothing when outdoors
• B. Report the onset of sore throat
• C. Eat plenty of potassium-rich food
• D. Change the position slowly

Correct answer: D

Rationale: The correct instruction for an elderly client taking both an ACE inhibitor and a calcium channel blocker is to change positions slowly. Both medications can lead to orthostatic hypotension, a sudden drop in blood pressure when changing positions, which can increase the risk of falls. Instructing the client to change positions slowly helps prevent falls. Wearing long-sleeved clothing when outdoors does not directly relate to the medication combination. Reporting the onset of a sore throat is important for monitoring potential side effects but is not specific to these medications. While potassium levels should be monitored with ACE inhibitors, eating plenty of potassium-rich foods without guidance can lead to hyperkalemia, a potential side effect of ACE inhibitors.

3. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Client reports difficulty breathing
• B. Client reports shortness of breath when lying flat
• C. Client reports swelling in the feet and ankles
• D. Client reports a metallic taste in the mouth

Correct answer: A

Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.

4. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?

• A. Administer a bronchodilator
• B. Encourage deep breathing and coughing
• C. Assess the client's oxygen saturation level
• D. Obtain an arterial blood gas

Correct answer: C

Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.

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