Nursing Elites

1. What is the most important intervention for a patient with suspected DVT?

• A. Administer anticoagulants
• B. Monitor oxygen levels
• C. Apply compression stockings
• D. Encourage ambulation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.

2. A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?

• A. Fundus firm and at the umbilicus.
• B. Heart rate 80/min.
• C. Blood pressure 130/78 mm Hg.
• D. A constant trickle of bright red blood from the vagina.

Correct answer: D

Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.

3. A client is receiving heparin therapy. Which of the following laboratory results indicates the client is receiving an effective dose of heparin?

• A. INR 1.5
• B. aPTT 60 seconds
• C. Platelets 150,000/mm³
• D. Potassium 4.0 mEq/L

Correct answer: B

Rationale: An aPTT of 60 seconds indicates the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for a clot to form, and a therapeutic range for heparin therapy is usually 1.5 to 2 times the control value, which is around 60-80 seconds. An INR of 1.5 is not related to heparin therapy, as it is commonly used to monitor warfarin therapy. Platelet count and potassium levels are not direct indicators of the effectiveness of heparin therapy.

4. A nurse is providing care for a client with thrombocytopenia. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to bleeding problems. Providing a stool softener helps prevent constipation, which in turn prevents straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is not directly linked to managing thrombocytopenia.

5. A nurse is caring for a client who has diabetes insipidus. Which of the following findings should the nurse expect?

• A. Weight gain
• B. Increased urine output
• C. Bradycardia
• D. Hyperactive bowel sounds

Correct answer: B

Rationale: Increased urine output is a key finding in clients with diabetes insipidus due to a deficiency of antidiuretic hormone. Weight gain (choice A) is not expected in diabetes insipidus as it is a condition characterized by excessive thirst and urination leading to fluid loss. Bradycardia (choice C) and hyperactive bowel sounds (choice D) are not typically associated with diabetes insipidus.

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