Nursing Elites

1. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

• A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
• B. Reporting an APTT above 45 seconds to the physician
• C. Assessing the patient for signs and symptoms of frank and occult bleeding
• D. All of the above

Correct answer: D

Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.

2. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

3. Which of the following measures is not recommended to prevent pressure ulcers?

• A. Massaging the reddened area with lotion
• B. Using a water or air mattress
• C. Adhering to a schedule for positioning and turning
• D. Providing meticulous skin care

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

4. Before rigor mortis occurs, what is the nurse responsible for?

• A. Providing a complete bath and dressing change
• B. Placing one pillow under the body’s head and shoulders
• C. Removing the body’s clothing and wrapping the body in a shroud
• D. Allowing the body to relax normally

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

5. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

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