Nursing Elites

1. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

2. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?

• A. Children who have varicella are contagious until vesicles are crusted
• B. Children who have varicella should receive the herpes zoster vaccination
• C. Children who have varicella should be placed in droplet precautions
• D. Children who have varicella are contagious 4 days before the first vesicle eruption

Correct answer: A

Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.

3. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 62/min
• D. Left foot is cool to the touch

Correct answer: D

Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.

4. Which diagnostic test is used to confirm tuberculosis (TB) infection?

• A. Chest X-ray
• B. Sputum culture
• C. Skin test (Mantoux)
• D. MRI

Correct answer: C

Rationale: The Mantoux skin test, also known as the Tuberculin Skin Test (TST), is used to confirm tuberculosis (TB) infection. This test involves injecting a small amount of tuberculin protein derivative under the top layer of the skin and then evaluating the immune system's response to the protein. A positive reaction indicates exposure to the TB bacteria. Chest X-rays are used to detect abnormalities in the lungs caused by TB but are not confirmatory. Sputum culture is used to identify the presence of TB bacteria in the sputum. MRIs are not typically used as a primary diagnostic tool for TB.

5. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous wound drainage
• B. Heart rate of 90/min
• C. Urine output of 30 mL/hr
• D. Temperature of 37.3°C (99.1°F)

Correct answer: C

Rationale: A urine output of 30 mL/hr is significantly low and indicates possible renal impairment or inadequate perfusion to the kidneys, which are critical for postoperative recovery. In this situation, decreased urine output could lead to fluid and electrolyte imbalances, affecting the client's overall condition. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention. Serosanguineous wound drainage is a normal finding in the early postoperative period and does not typically warrant immediate concern. A heart rate of 90/min is within the normal range and may be expected in a postoperative client due to the stress response. A temperature of 37.3°C (99.1°F) is slightly elevated but not a concerning finding in isolation postoperatively.

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