Nursing Elites

1. A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

• A. Platelet count of 200,000/mm³
• B. aPTT of 50 seconds
• C. Hemoglobin of 14 g/dL
• D. INR of 1.0

Correct answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

2. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

3. A healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

• A. Hyperthyroidism.
• B. Thrombophlebitis.
• C. Diverticulosis.
• D. Hypocalcemia.

Correct answer: B

Rationale: Thrombophlebitis is a contraindication for the use of oral contraceptives due to the increased risk of complications such as thromboembolism. Hyperthyroidism, diverticulosis, and hypocalcemia are not contraindications for oral contraceptives. Hyperthyroidism may affect the metabolism of contraceptives but does not contraindicate their use. Diverticulosis and hypocalcemia do not directly impact the safety or effectiveness of oral contraceptives.

4. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?

• A. Pregabalin
• B. Lorazepam
• C. Colchicine
• D. Codeine

Correct answer: A

Rationale: The correct answer is A: Pregabalin. Pregabalin is a first-line medication for treating pain in clients with fibromyalgia. It works by decreasing the number of pain signals sent out by damaged nerves. Choice B, Lorazepam, is a benzodiazepine used for anxiety and not indicated for fibromyalgia pain. Choice C, Colchicine, is used to treat gout by reducing inflammation and not indicated for fibromyalgia. Choice D, Codeine, is an opioid analgesic that is not typically recommended for fibromyalgia due to concerns about tolerance and dependence.

5. A nurse is caring for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Use physical restraints to prevent wandering.
• C. Ensure that the client wears an identification bracelet at all times.
• D. Keep the client's bed in the lowest position.

Correct answer: C

Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.

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