Nursing Elites

1. What is the best way to assess a patient's respiratory function after surgery?

• A. Check oxygen saturation
• B. Auscultate lung sounds
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.

2. A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. The nurse should monitor the client for which of the following therapeutic effects of this medication?

• A. Improved mental status.
• B. Increased urine output.
• C. Decreased serum ammonia.
• D. Decreased bilirubin levels.

Correct answer: C

Rationale: The correct answer is C: Decreased serum ammonia. Lactulose is prescribed to decrease serum ammonia levels in clients with cirrhosis and hepatic encephalopathy. By reducing serum ammonia, lactulose helps improve the mental status of these clients. Therefore, monitoring for decreased serum ammonia is crucial to assess the effectiveness of lactulose therapy. Choice A (Improved mental status) is indirectly related as it is the desired outcome of decreasing ammonia levels. Choices B (Increased urine output) and D (Decreased bilirubin levels) are not directly associated with the therapeutic effects of lactulose in cirrhosis and hepatic encephalopathy.

3. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so.
• B. The proxy can make financial decisions if the need arises.
• C. The proxy can make treatment decisions if the client is under anesthesia.
• D. The proxy should manage legal issues for the client.

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

4. Which lab value is critical for a patient on 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. Activated Partial Thromboplastin Time (aPTT) is crucial for patients on heparin therapy as it helps determine the clotting ability of the blood. By monitoring aPTT, healthcare providers can adjust the dosage of heparin to maintain therapeutic levels and prevent bleeding complications. Monitoring INR is more commonly associated with warfarin therapy, not heparin. Monitoring platelet count is important for assessing the risk of bleeding or clotting disorders but is not specific to heparin therapy. Monitoring sodium levels is not directly related to assessing the effectiveness or safety of heparin therapy.

5. How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?

• A. Encourage compliance through education
• B. Contact the healthcare provider
• C. Document the refusal
• D. Explore alternative treatment options

Correct answer: A

Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.

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