Nursing Elites

1. The client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Complete blood count (CBC)
• B. Activated partial thromboplastin time (aPTT)
• C. Serum electrolytes
• D. Liver function tests

Correct answer: B

Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor the effectiveness of anticoagulant therapy, especially with heparin. A prolonged aPTT indicates effective anticoagulation, reducing the risk of further clot formation in the client with deep vein thrombosis (DVT). The other options, such as complete blood count (CBC), serum electrolytes, and liver function tests, do not directly assess the therapeutic effectiveness of anticoagulant therapy. Therefore, the correct answer is B.

2. A client with hypertension is prescribed enalapril (Vasotec). The nurse should monitor the client for which adverse effect?

• A. Hypotension
• B. Hypertension
• C. Tachycardia
• D. Hyperglycemia

Correct answer: A

Rationale: Enalapril, an ACE inhibitor, can lead to hypotension, particularly following the initial dose or dosage escalation. This effect is due to the medication's mechanism of action in dilating blood vessels, which can result in lowered blood pressure. Monitoring for hypotension is crucial to prevent complications such as dizziness, lightheadedness, or fainting in clients taking enalapril. Choices B, C, and D are incorrect because enalapril does not typically cause hypertension, tachycardia, or hyperglycemia as adverse effects.

3. The client is starting therapy with digoxin (Lanoxin). What instruction should the nurse reinforce about the medication?

• A. Take the medication with meals.
• B. Avoid dairy products.
• C. Monitor for yellow or blurred vision.
• D. Increase potassium-rich foods in the diet.

Correct answer: C

Rationale: The correct answer is C: 'Monitor for yellow or blurred vision.' When a client is taking digoxin, it is crucial to monitor for signs of toxicity, such as yellow or blurred vision, as these can indicate an adverse reaction. Reporting these visual disturbances promptly to the healthcare provider is important for further evaluation and management to prevent potential complications. Choices A, B, and D are incorrect because taking digoxin with meals, avoiding dairy products, or increasing potassium-rich foods are not specific instructions related to monitoring for adverse effects of digoxin therapy.

4. A client with a diagnosis of heart failure is being discharged. What information should the nurse emphasize to the client regarding the use of a daily weight log?

• A. Report any weight gain of more than 2 pounds in a day
• B. Weigh yourself after eating breakfast each morning
• C. Use the same scale each day to check your weight
• D. Record your weight daily and report any changes

Correct answer: A

Rationale: The correct answer is A: 'Report any weight gain of more than 2 pounds in a day.' Sudden weight gain of more than 2 pounds in a day may indicate fluid retention and worsening heart failure. This information is crucial for early intervention and monitoring of the client's condition. Weighing after eating breakfast (choice B) may not provide consistent results due to varying food and fluid intake. Using the same scale each day (choice C) ensures accuracy and consistency in weight measurements. Recording weight daily (choice D) is more frequent than necessary and may not be practical for all clients. It is essential to focus on significant weight changes to prevent unnecessary alarm or confusion.

5. Prior to a cardiac catheterization, what instruction should the client be reminded of?

• A. You will need to be NPO for 6 to 8 hours before the procedure.
• B. You will not be able to move around during the procedure.
• C. You will be required to lie still for several hours after the test.
• D. You will not have to drink any fluids immediately before the test.

Correct answer: A

Rationale: Being NPO (nothing by mouth) for 6 to 8 hours before a cardiac catheterization is crucial to prevent complications such as aspiration during the procedure. This helps ensure the safety and accuracy of the test results by minimizing the risk of food or liquid in the stomach interfering with the procedure. Choice B is incorrect because the client will need to lie still during the procedure to ensure its accuracy. Choice C is incorrect as the client is typically required to lie flat for a few hours after the test, not several hours. Choice D is incorrect as the client is usually not allowed to drink fluids immediately before the test to prevent complications.

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