Nursing Elites

1. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

• A. Localized warmth
• B. Calf pain
• C. Swelling in the affected leg
• D. Hematuria

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

2. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

3. A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?

• A. Being NPO helps reduce the risk of nausea.
• B. I should not eat or drink anything to prevent complications during surgery.
• C. NPO reduces the risk of aspiration during surgery.
• D. NPO helps ensure the stomach is empty during surgery.

Correct answer: C

Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.

4. A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?

• A. Increased white blood cell count
• B. Crackles heard on lung auscultation
• C. Productive cough with green sputum
• D. Decreased respiratory rate from 24 to 18 breaths per minute

Correct answer: D

Rationale: A decrease in respiratory rate indicates that the client's breathing is becoming more stable, which suggests an improvement in their condition. Respiratory rate is a critical indicator of respiratory status and oxygenation. Increased white blood cell count (choice A) suggests ongoing infection, crackles on lung auscultation (choice B) indicate fluid in the lungs, and productive cough with green sputum (choice C) may indicate persistent infection or airway inflammation, which do not necessarily reflect improvement in pneumonia.

5. A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

• A. Anticholinergics
• B. Beta blockers
• C. Alpha blockers
• D. Diuretics

Correct answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

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