Nursing Elites

1. A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.

2. Which lab value should be monitored in patients receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

3. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?

• A. Prothrombin time (PT)
• B. International Normalized Ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.

4. What is the most important nursing assessment post-surgery?

• A. Monitor vital signs
• B. Monitor blood pressure
• C. Monitor the surgical site
• D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

5. How should fluid balance be assessed in a patient with heart failure?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

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