Nursing Elites

1. A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?

• A. aPTT 75 seconds.
• B. INR 1.2.
• C. Hemoglobin 10 g/dL.
• D. Fibrinogen level 350 mg/dL.

Correct answer: A

Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.

2. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

3. What is the best intervention for a patient with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

4. How should a healthcare professional assess a patient for dehydration?

• A. Check for skin turgor
• B. Monitor blood pressure
• C. Check for dry mucous membranes
• D. Monitor urine output

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

5. A nurse is reviewing the laboratory results of a client who is at 36 weeks of gestation. The nurse should report which of the following laboratory results to the provider?

• A. Hemoglobin 11.2 g/dL
• B. Platelet count 148,000/mm3
• C. Leukocyte count 9,000/mm3
• D. Blood glucose 80 mg/dL

Correct answer: A

Rationale: A hemoglobin level of 11.2 g/dL is below the normal range for a client who is 36 weeks gestation and should be reported to the provider.

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