Nursing Elites

1. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?

• A. INR of 1.5
• B. Platelet count of 200,000/mm³
• C. Hemoglobin of 12 g/dL
• D. aPTT of 70 seconds

Correct answer: A

Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.

2. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

3. A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?

• A. I will place the bed in the lowest position
• B. I will tighten my abdominal muscles prior to moving
• C. I will keep my legs straight to provide more power in the lift
• D. I will twist at the waist while pulling the draw sheet

Correct answer: B

Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.

4. When conducting an admission assessment, the LPN should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?

• A. Complementary healing practices interfere with the efficacy of the medical model of treatment.
• B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
• C. Many complementary healing practices can be used in conjunction with conventional practices.
• D. Conventional medical practices will ultimately replace the use of complementary healing practices.

Correct answer: C

Rationale: When considering the use of complementary healing practices, it is important to acknowledge that many of these practices can be safely integrated with conventional treatments to provide holistic care. Choice A is incorrect because complementary healing practices can complement traditional medical approaches rather than interfere with their efficacy. Choice B is incorrect as interactions between conventional medications and folk remedies may vary, but not all interactions lead to adverse effects. Choice D is incorrect as conventional medical practices and complementary healing practices can coexist and each offer benefits in healthcare.

5. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?

• A. Knee picture
• B. Ankle picture
• C. Elbow picture
• D. Wrist picture

Correct answer: A

Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.

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