Nursing Elites

1. Which lab value should be monitored in patients receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

2. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

• A. Stands with feet together when lifting a client up in bed.
• B. Raises the client's head of bed before pulling the client up.
• C. Uses a mechanical lift to move a client from bed to chair.
• D. Places a gait belt around the client's upper chest before assisting the client to stand.

Correct answer: C

Rationale: The correct answer is C because using a mechanical lift is an ergonomic practice that ensures safe body mechanics and prevents injuries. Choice A is incorrect as standing with feet together when lifting a client does not promote proper body mechanics. Choice B is incorrect as raising the client's head of bed before pulling the client up is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's upper chest is a safety measure for assisting with standing but does not address ergonomic principles.

3. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

4. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

5. What is the best nursing action for a patient experiencing shortness of breath?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide IV fluids

Correct answer: A

Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.

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