Nursing Elites

1. The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?

• A. Drinks adequate fluids.
• B. Void without difficulty.
• C. Feels less thirsty.
• D. Drinks 240 mL of fluid five times during the shift.

Correct answer: D

Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.

2. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

• A. Continue the heparin infusion as prescribed.
• B. Decrease the heparin infusion rate.
• C. Increase the heparin infusion rate.
• D. Stop the heparin infusion and notify the healthcare provider.

Correct answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

3. A public health nurse is planning an educational campaign to reduce the incidence of hypertension in the community. Which group should be the primary target of this campaign?

• A. adolescents
• B. young adults
• C. middle-aged adults
• D. older adults

Correct answer: C

Rationale: The correct answer is C, middle-aged adults. Middle-aged adults are at a higher risk for developing hypertension due to lifestyle factors and aging. Targeting this group for preventive measures such as dietary changes, exercise, and stress management can have a significant impact on reducing the incidence of hypertension. Choices A, B, and D are less appropriate targets as adolescents generally have lower rates of hypertension, young adults are less likely to be affected by hypertension at this stage, and older adults may already have established hypertension or comorbidities that could make prevention more challenging.

4. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 before administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

• A. Administer the dose as prescribed.
• B. Hold the medication.
• C. Call the healthcare provider.
• D. Repeat the vital signs in 30 minutes.

Correct answer: A

Rationale: The correct action is to administer the dose as prescribed. Verapamil slows sinoatrial nodal automaticity and delays atrioventricular nodal conduction, which helps in slowing the ventricular rate. The heart rate of 92 and blood pressure of 110/76 are within an acceptable range for administering verapamil in a client with atrial flutter. Holding the medication, calling the healthcare provider, or repeating the vital signs in 30 minutes are not necessary based on the vital signs obtained and the action of verapamil in this scenario.

5. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

Similar Questions