Nursing Elites

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

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

Correct answer: B

Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.

2. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

• A. Light yellow coloring of the client's skin and eyes.
• B. The client's blood pressure reading of 184/88 mm Hg.
• C. The client vomits 20 ml of clear yellowish fluid.
• D. The IV insertion site is red, swollen, and leaking IV fluid.

Correct answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

3. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

• A. Low oxygen levels are present in the blood.
• B. High levels of carbon dioxide have accumulated in the blood.
• C. Increased bicarbonate levels are causing alkalosis.
• D. Respiratory rate is increased, causing hyperventilation.

Correct answer: B

Rationale: High levels of carbon dioxide in the blood lead to respiratory acidosis due to inadequate ventilation. The correct answer is B. In respiratory acidosis, the accumulation of carbon dioxide in the blood occurs due to inadequate exhalation, leading to acidosis. Choice A is incorrect as low oxygen levels are related to hypoxemia, not respiratory acidosis. Choice C is incorrect as increased bicarbonate levels would lead to alkalosis, not acidosis. Choice D is incorrect as an increased respiratory rate causing hyperventilation would actually help decrease carbon dioxide levels, not lead to respiratory acidosis.

4. Following a bout of diarrhea, which foods should be offered to the school-age child?

• A. Apricots and peaches
• B. Chocolate milk
• C. Applesauce and milk
• D. Bananas and rice

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

5. A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?

• A. Walking.
• B. Running.
• C. Swimming.
• D. Weight lifting.

Correct answer: C

Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.

Similar Questions