Nursing Elites

1. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which response should the nurse provide?

• A. Respite care provides medical support to the client.
• B. Respite care assists with financial planning for the client’s needs.
• C. Respite care provides long-term housing.
• D. Respite care allows the primary caregiver time away from day-to-day care responsibilities.

Correct answer: D

Rationale: The correct answer is D. Respite care is designed to give primary caregivers temporary relief from the responsibilities of care, allowing them to take a break. Choice A is incorrect because respite care is not primarily focused on providing medical support to the client. Choice B is incorrect as respite care does not specifically assist with financial planning for the client's needs. Choice C is incorrect as respite care does not provide long-term housing, but rather short-term relief for caregivers.

2. A healthcare professional is preparing to administer a dose of sertraline. Which of the following should the healthcare professional assess first?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Mood changes

Correct answer: A

Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.

3. A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?

• A. Platelet count
• B. Partial thromboplastin time (PTT)
• C. Prothrombin time (PT)
• D. Bleeding time

Correct answer: B

Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.

4. When teaching about safety risks for adolescents, what should be included?

• A. Adolescents are more likely to follow rules
• B. Peer influence to participate in high-risk behaviors can lead to injury
• C. Most injuries occur during sports activities
• D. Adolescents are aware of the dangers of substance use

Correct answer: B

Rationale: When educating about safety risks for adolescents, it is crucial to address the impact of peer influence on engaging in high-risk behaviors, which can result in injuries. Choice A is incorrect because adolescents are known to sometimes take risks and not always follow rules. Choice C is incorrect as injuries among adolescents can also happen outside of sports activities. Choice D is incorrect as adolescents may not always be fully aware of the dangers of substance use.

5. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

• A. Redness at the site
• B. Warmth around the site
• C. Edema
• D. Pain at the site

Correct answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.

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