Nursing Elites

1. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

• A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
• B. Reporting an APTT above 45 seconds to the physician
• C. Assessing the patient for signs and symptoms of frank and occult bleeding
• D. All of the above

Correct answer: D

Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.

2. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

3. During discharge teaching, a client informs the nurse about a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?

• A. I will decrease my fluid intake while taking this medication.
• B. I will expect to have black, tarry stools.
• C. I will take my medication with meals.
• D. I will monitor for weight loss while on this medication.

Correct answer: C

Rationale: Taking prednisone with meals can help reduce the risk of gastrointestinal upset and irritation. It is important for the client to understand how to take the medication correctly to maximize its effectiveness and minimize potential side effects. Monitoring for weight loss or changes in stools may be important but does not directly relate to the administration of the medication with meals.

4. When is additional Vitamin C not required?

• A. Infancy
• B. Young adulthood
• C. Childhood
• D. Pregnancy

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

5. Which of the following is not a cause of tachycardia?

• A. Fever
• B. Exercise
• C. Sympathetic nervous system stimulation
• D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

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