a nurse is caring for a client receiving heparin which of the following should the nurse monitor
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

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

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 nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

3. A nurse is caring for a client 4 hours postoperative following a thyroidectomy who reports fullness in the throat. What should the nurse assess for?

Correct answer: B

Rationale: Fullness in the throat after a thyroidectomy could indicate bleeding or a hematoma, which can compress the airway, so hemorrhage is the priority concern. Hypocalcemia typically presents with symptoms like tingling around the mouth or in the extremities, muscle cramps, or seizures, not fullness in the throat. Hypoxia would manifest with symptoms like shortness of breath, confusion, or cyanosis, rather than a feeling of fullness in the throat. Hypothyroidism symptoms include fatigue, weight gain, and cold intolerance, but it does not typically cause acute fullness in the throat postoperatively.

4. A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

Correct answer: A

Rationale: A TPN solution with an oily appearance and a layer of fat on top indicates that the solution is 'cracked' and should not be used as it may have separated or deteriorated. This finding suggests a need to obtain a new bag of TPN before administering. Options B, C, and D are normal aspects of TPN administration. Option B confirms the presence of essential components in the TPN solution, option C provides information about the preparation time, and option D ensures proper identification and matching of the TPN with the correct client.

5. A nurse is assessing a client for signs of heart failure. Which of the following findings should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. Peripheral edema, the accumulation of fluid causing swelling in the extremities, is a classic sign of heart failure due to fluid overload. This occurs because the heart's reduced pumping efficiency leads to fluid backup in the circulatory system. Choices A, C, and D are incorrect. Decreased heart rate is not typically associated with heart failure; instead, tachycardia or an increased heart rate may be observed. Increased energy levels are not an expected finding in heart failure, as this condition often causes fatigue and weakness. Hyperglycemia is not a direct sign of heart failure; however, it can be present in individuals with uncontrolled diabetes or as a result of certain treatments, but it is not a specific indicator of heart failure.

Similar Questions

A nurse is reviewing the guidelines for reporting nationally notifiable infectious diseases. What disease should the nurse report to the CDC?
When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?
A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?
A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?
A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses