Nursing Elites

1. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

2. A client with diabetes mellitus is receiving education on foot care. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes.
• B. Cut toenails straight across.
• C. Use a heating pad to warm the feet.
• D. Soak feet in warm water daily.

Correct answer: B

Rationale: The correct answer is B: Cut toenails straight across. This instruction is vital for clients with diabetes as it helps prevent ingrown toenails and infections, reducing the risk of foot ulcers. Applying lotion between the toes (choice A) should be avoided as it can create a moist environment prone to fungal infections. Using a heating pad (choice C) can lead to burns or injuries due to reduced sensation common in diabetes. Soaking feet in warm water daily (choice D) can also increase the risk of skin breakdown and should be avoided.

3. A nurse is sitting with the partner of a client who recently died. Which of the following actions should the nurse take to facilitate mourning?

• A. Encourage the partner to ask for help when needed
• B. Suggest the partner avoid discussing their feelings
• C. Recommend immediate return to daily activities
• D. Advise the partner to remain strong

Correct answer: A

Rationale: The correct action for the nurse to take to facilitate mourning is to encourage the partner to ask for help when needed. Grieving is a challenging process, and offering support and encouragement to seek help can be beneficial. Choice B is incorrect because avoiding discussing feelings can hinder the grieving process by suppressing emotions. Choice C is also incorrect as an immediate return to daily activities may not allow the partner to properly process their grief. Choice D is not the best approach as advising the partner to 'remain strong' may discourage the expression of emotions and seeking support, which are essential in the mourning process.

4. A client is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet?

• A. Yogurt
• B. Apples
• C. Raisins
• D. Cheddar cheese

Correct answer: C

Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, which can help prevent or address iron deficiency anemia. Yogurt (Choice A) and cheddar cheese (Choice D) are not significant sources of iron. While apples (Choice B) are a healthy fruit, they do not contain as much iron as raisins.

5. A nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?

• A. Administer oxygen
• B. Reposition the client
• C. Prepare for delivery
• D. Increase IV fluids

Correct answer: B

Rationale: The correct answer is to reposition the client. Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation. Administering oxygen may be necessary in some situations, but repositioning the client takes precedence to address the underlying cause of variable decelerations. While preparing for delivery is important, addressing the immediate concern of variable decelerations by repositioning the client is the priority. Increasing IV fluids is not the priority in this situation as it does not directly address the cause of variable decelerations.

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