Nursing Elites

1. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

2. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?

• A. Prothrombin time (PT)
• B. International Normalized Ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.

3. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

4. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding tendencies. Providing a stool softener helps prevent constipation and straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is important for oral hygiene but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to preventing infections in immunocompromised clients. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems but is not specifically targeted at managing thrombocytopenia.

5. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

• A. Platelets 250,000/mm³
• B. aPTT 60 seconds
• C. Hemoglobin 15 g/dL
• D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

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