Nursing Elites

1. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. Platelet count
• C. Activated partial thromboplastin time (aPTT)
• D. International normalized ratio (INR)

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works by prolonging the clotting time, which is reflected in the aPTT results. Monitoring aPTT helps ensure the patient is within the therapeutic range and not at risk of bleeding or clotting complications. Prothrombin time (PT) (Choice A) primarily measures the extrinsic pathway of coagulation and is used to monitor warfarin therapy, not heparin. Platelet count (Choice B) assesses the number of platelets present in the blood and is not specific to monitoring heparin therapy. International normalized ratio (INR) (Choice D) is used to monitor warfarin therapy, not heparin.

2. The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?

• A. Hyperpigmentation of the skin.
• B. Hypotension.
• C. Moon face and buffalo hump.
• D. Weight loss.

Correct answer: C

Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excess production of corticosteroids leads to redistribution of fat, particularly in the face (moon face) and between the shoulders (buffalo hump). Hyperpigmentation of the skin is actually associated with Addison's disease, not Cushing's syndrome (choice A). Hypotension is not a typical finding in Cushing's syndrome; instead, hypertension is more commonly seen due to the effects of excess cortisol (choice B). Weight gain, rather than weight loss, is a common symptom of Cushing's syndrome due to the metabolic disturbances caused by excess cortisol (choice D).

3. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?

• A. Check the client's vital signs before starting the transfusion.
• B. Verify the client's identity and blood compatibility.
• C. Administer the blood with normal saline.
• D. Monitor the client for the first 15 minutes of the transfusion.

Correct answer: B

Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.

4. A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?

• A. Chorionic villus sampling under ultrasound.
• B. Amniocentesis and fetal monitoring.
• C. Ultrasonography and nonstress test.
• D. Oxytocin challenge test and fetal heart rate monitoring.

Correct answer: C

Rationale: A biophysical profile (BPP) is a prenatal test that assesses the well-being of the fetus. It typically includes ultrasonography to evaluate fetal movements, muscle tone, breathing movements, and amniotic fluid volume. Additionally, a nonstress test is performed to monitor the fetal heart rate in response to its movements. These tests help in determining the overall health and viability of the fetus, making them essential components of prenatal care for assessing fetal well-being.

5. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?

• A. The client's extremities are paralyzed.
• B. The peripheral nerve stimulator causes twitching.
• C. The client clenches fist upon command.
• D. The client's Glasgow Coma Scale score is 14.

Correct answer: A

Rationale: The correct answer is A. Tubocurarine chloride is a neuromuscular blocker that works by causing paralysis of skeletal muscles. Therefore, if the client's extremities are paralyzed, it indicates that the medication is effective in achieving the desired muscle relaxation necessary for mechanical ventilation. Choices B and C are incorrect as they suggest muscle activity, which would not be expected with the administration of a neuromuscular blocker. Choice D is unrelated to the effectiveness of tubocurarine chloride.

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