Nursing Elites

1. How should a healthcare provider monitor a patient receiving heparin therapy?

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

Correct answer: A

Rationale: The correct answer is to monitor aPTT (activated partial thromboplastin time) when a patient is receiving heparin therapy. aPTT monitoring is essential for assessing the therapeutic effectiveness of heparin, ensuring the patient is within the desired therapeutic range to prevent both clotting and bleeding. Monitoring platelet count (Choice B) is important for assessing for heparin-induced thrombocytopenia but is not the primary monitoring parameter for heparin therapy. Monitoring sodium levels (Choice C) and calcium levels (Choice D) are not directly related to assessing the therapeutic effectiveness or potential side effects of heparin therapy.

2. A nurse is caring for a client who has septic shock. Which of the following findings should the nurse report to the provider?

• A. Temperature of 38°C (100.4°F).
• B. Urinary output of 40 mL/hr.
• C. Heart rate of 92/min.
• D. Capillary refill time of 2 seconds.

Correct answer: B

Rationale: The correct answer is B. A urinary output of 40 mL/hr is below the expected range and should be reported to the provider as it may indicate impaired kidney function, which is crucial to monitor in a client with septic shock. Choices A, C, and D are within acceptable ranges for a client with septic shock and do not indicate immediate concerns. A temperature of 38°C (100.4°F) is slightly elevated but can be expected in septic shock. A heart rate of 92/min is within the normal range for an adult. A capillary refill time of 2 seconds is also normal, indicating adequate peripheral perfusion.

3. Which lab value should be monitored for a patient on warfarin therapy?

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

Correct answer: A

Rationale: The correct answer is to monitor INR for a patient on warfarin therapy. INR monitoring is crucial as it helps assess the therapeutic effectiveness and safety of warfarin. INR stands for International Normalized Ratio, and it measures the blood's ability to clot. Monitoring potassium levels (Choice B) is not specific to warfarin therapy. Monitoring platelet count (Choice C) is important but not the primary lab value for assessing warfarin therapy. Monitoring sodium levels (Choice D) is not directly related to warfarin therapy.

4. Which assessment finding is most concerning in a patient receiving morphine?

• A. Hypotension
• B. Bradycardia
• C. Respiratory depression
• D. Hypertension

Correct answer: C

Rationale: The correct answer is C, respiratory depression. When a patient is receiving morphine, respiratory depression is the most concerning side effect because it can lead to serious complications, including respiratory arrest and even death. Monitoring the patient's respiratory status is crucial to ensure early detection of any signs of respiratory depression. Choices A, B, and D are incorrect because although hypotension, bradycardia, and hypertension can occur as side effects of morphine, they are not as immediately life-threatening as respiratory depression in this context.

5. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

• A. White blood cell count 6,000/mm3
• B. Positive antinuclear antibody (ANA) titer
• C. Platelet count 220,000/mm3
• D. Blood urea nitrogen (BUN) 15 mg/dL

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

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