Nursing Elites

1. How should bleeding in a patient on warfarin be monitored?

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

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

2. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 140/min.
• B. A bulging anterior fontanel.
• C. Respiratory rate 50/min.
• D. Blood glucose 45 mg/dL.

Correct answer: D

Rationale: A blood glucose level of 45 mg/dL is below the normal range for a newborn and indicates hypoglycemia, which can lead to serious complications if left untreated. Therefore, this finding should be reported to the provider immediately. Choices A, B, and C are within normal ranges for a newborn and do not require immediate reporting. A heart rate of 140/min, a bulging anterior fontanel, and a respiratory rate of 50/min are all common findings in a newborn and do not raise immediate concerns.

3. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

4. How should a healthcare professional assess a patient's pain level post-surgery?

• A. Use a pain rating scale
• B. Check vital signs
• C. Observe for non-verbal cues
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse every 30 minutes.
• C. Obtain a prescription for restraints within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.

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