Nursing Elites

1. While caring for a client receiving Heparin therapy, which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the therapy?

• A. PT
• B. INR
• C. aPTT
• D. Platelet count

Correct answer: C

Rationale: The nurse should monitor the aPTT (activated partial thromboplastin time) when caring for a client receiving Heparin therapy. The aPTT reflects the intrinsic pathway of the clotting cascade and is used to monitor the effectiveness of heparin, which primarily affects this pathway by potentiating antithrombin III. Monitoring the aPTT helps ensure that the client's blood is within the therapeutic range to prevent thrombus formation. Choices A, B, and D are incorrect. PT (Prothrombin Time) and INR (International Normalized Ratio) are used to monitor Warfarin therapy, not Heparin. Platelet count is important in assessing for thrombocytopenia but is not a specific indicator of Heparin therapy effectiveness.

2. What is a severe adverse effect of warfarin?

• A. Bleeding
• B. Arrhythmias
• C. Blurred vision
• D. Bradycardia

Correct answer: A

Rationale: A severe adverse effect of warfarin is bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors, which can lead to an increased risk of bleeding. Excessive bleeding can occur internally or externally, and it is crucial for individuals taking warfarin to be aware of this potential complication and seek medical attention if they experience any signs of bleeding. Arrhythmias, blurred vision, and bradycardia are not typically associated with warfarin use, making them incorrect choices.

3. A client in an acute care facility is receiving IV Nitroprusside for hypertensive crisis. The nurse should monitor the client for which of the following adverse reactions to this medication?

• A. Intestinal ileus
• B. Neutropenia
• C. Delirium
• D. Hyperthermia

Correct answer: C

Rationale: The correct answer is C: Delirium. When IV Nitroprusside is infused at high dosages, it can lead to thiocyanate toxicity, causing mental status changes such as delirium. It is crucial to monitor the thiocyanate levels to ensure they remain below 10 mg/dL during therapy to prevent adverse effects. Choices A, B, and D are incorrect because IV Nitroprusside is not commonly associated with intestinal ileus, neutropenia, or hyperthermia. Monitoring for delirium is crucial due to the risk of thiocyanate toxicity.

4. A client has a new prescription for Allopurinol. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. Increase your fluid intake.
• C. Avoid foods high in calcium.
• D. Take this medication with meals.

Correct answer: B

Rationale: Allopurinol can cause kidney stones due to the formation of uric acid crystals, so it is crucial for the client to increase their fluid intake. Adequate hydration helps to prevent the formation of kidney stones by diluting the urine and promoting the excretion of uric acid. Therefore, advising the client to increase their fluid intake is essential in preventing this adverse effect while taking Allopurinol.

5. A client with a new prescription for an antihypertensive medication is being provided discharge instructions by a nurse. Which of the following statements should the nurse give?

• A. Be sure to limit your potassium intake while taking the medication.
• B. You should check your blood pressure every 8 hours while taking this medication.
• C. Your medication dosage will be increased if you develop tachycardia.
• D. Change positions slowly when you move from sitting to standing.

Correct answer: D

Rationale: The correct statement for the nurse to provide is to instruct the client to change positions slowly when moving from sitting to standing. This is crucial because antihypertensive medications can cause orthostatic hypotension, leading to dizziness or lightheadedness when changing positions quickly. Checking blood pressure every 8 hours is unnecessary and could lead to over-monitoring. There is no direct relationship between the medication and potassium intake. Increasing the medication dosage due to tachycardia is not a typical response and may not be accurate.

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