Nursing Elites

1. A client with a diagnosis of deep vein thrombosis (DVT) has been placed on bed rest. The LPN/LVN should reinforce which instruction to the client to prevent complications?

• A. Perform ankle pumps and circles every 1 to 2 hours.
• B. Use a heating pad to relieve pain in the affected leg.
• C. Keep the affected leg flat and avoid elevation.
• D. Wear tight compression stockings to prevent swelling.

Correct answer: A

Rationale: Performing ankle pumps and circles every 1 to 2 hours is crucial for a client with DVT on bed rest. These exercises promote venous return, preventing stasis and reducing the risk of complications such as pulmonary embolism. Ankle pumps help activate the calf muscle pump, assisting in propelling blood back to the heart and preventing blood clots from forming or worsening. Choice B is incorrect because using a heating pad can increase blood flow to the area, potentially dislodging a clot. Choice C is incorrect because elevation helps reduce swelling and improve venous return. Choice D is incorrect because although compression stockings can be beneficial, they are not the most important instruction for preventing complications in this scenario.

2. A client has a new prescription for furosemide. Which of the following statements should the nurse include in the teaching?

• A. Take the medication in the morning.
• B. Monitor for muscle weakness.
• C. Eat foods high in potassium.
• D. Expect weight gain.

Correct answer: C

Rationale: The correct statement that the nurse should include in the teaching for a client prescribed furosemide is to eat foods high in potassium. Furosemide can lead to potassium depletion (hypokalemia) due to increased urine output. Consuming potassium-rich foods like bananas, oranges, spinach, and potatoes can help prevent this electrolyte imbalance. Choices A, B, and D are incorrect because taking furosemide in the morning, monitoring for muscle weakness, and expecting weight gain are not directly related to the potential side effects or necessary dietary adjustments when taking furosemide.

3. The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?

• A. Mild dyspnea after walking 10 feet
• B. Minimal chest pain rated 1 on a 1-to-10 pain scale
• C. Pulse rate that increases from 68 to 94 beats per minute
• D. Blood pressure that increases from 114/82 to 118/86 mm Hg

Correct answer: D

Rationale: A slight increase in blood pressure without significant symptoms indicates that the client is tolerating the activity. In this scenario, a mild increase in blood pressure without other symptoms is a positive sign of tolerance to ambulation despite the underlying condition of bacterial endocarditis. Choices A, B, and C are not the best indicators of tolerance to ambulation in this case. Mild dyspnea after walking a short distance, minimal chest pain, and an increase in pulse rate are common signs that the activity might not be well-tolerated by the client with a history of bacterial endocarditis.

4. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

• A. I am considering cutting my workload.
• B. I need to cut down on cigarette smoking.
• C. I am so relieved that my heart is repaired.
• D. I need to adhere to my dietary restrictions.

Correct answer: B

Rationale: The correct answer is B because cutting down on cigarette smoking is crucial for improving heart health after angioplasty. Smoking cessation helps in reducing the risk of complications and promotes better outcomes. Choices A and C are not directly related to post-angioplasty care. While reducing workload may be beneficial, it is not specifically related to the client's cardiac health. Feeling relieved that the heart is repaired is a positive emotional response but does not reflect understanding of the necessary measures. Adhering to dietary restrictions is important, but in this scenario, smoking cessation takes higher priority due to its immediate impact on heart health.

5. A client is receiving heparin therapy. Which of the following laboratory tests should be monitored to evaluate the effectiveness of the therapy?

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

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the most appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works on the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps assess its anticoagulant effect. Therapeutic levels of aPTT for clients on heparin therapy are typically 1.5 to 2.5 times the control value. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, which acts on the extrinsic pathway of the coagulation cascade. Complete blood count (CBC) is not specific for monitoring the effectiveness of heparin therapy.

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