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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.
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A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Apply a moisture barrier ointment.
Correct Answer: D
Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.
A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication intramuscularly.
- B. Inject the medication into the lateral abdominal wall.
- C. Massage the injection site after administration.
- D. Discard the prefilled syringe after expelling the air bubble.
Correct Answer: B
Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.
A client with chronic kidney disease is being educated by a nurse about dietary modifications. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of potassium-rich foods.
- B. I will limit my protein intake to prevent further kidney damage.
- C. I will avoid consuming foods high in phosphorus.
- D. I will increase my intake of dairy products to support kidney function.
Correct Answer: B
Rationale: The correct answer is B. Limiting protein intake is crucial for clients with chronic kidney disease as it helps prevent further kidney damage. Increasing intake of potassium-rich foods (choice A) is not recommended for clients with kidney disease as high potassium levels can be harmful. Avoiding foods high in phosphorus (choice C) is important, but limiting protein intake is a higher priority. Increasing dairy product intake (choice D) is not ideal for clients with kidney disease as they may need to monitor their phosphorus intake from such foods.
A nurse is assessing a client who has gastroesophageal reflux disease (GERD). Which of the following findings should the nurse expect?
- A. Abdominal distention
- B. Burning sensation in the chest
- C. Constipation
- D. Frequent belching
Correct Answer: B
Rationale: The correct answer is B: Burning sensation in the chest. A burning sensation in the chest is a classic symptom of gastroesophageal reflux disease (GERD). Abdominal distention (Choice A) is not typically associated with GERD; it is more commonly seen in conditions like bowel obstruction. Constipation (Choice C) is not a hallmark symptom of GERD, as it is more related to gastrointestinal motility issues. Frequent belching (Choice D) can occur with GERD, but it is not as specific or characteristic as the burning sensation in the chest.
A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings is an indication for hemodialysis?
- A. BUN 16 mg/dL
- B. Serum magnesium 1.8 mg/dL
- C. Serum phosphorus 4.0 mg/dL
- D. Glomerular filtration rate of 14 mL/min
Correct Answer: D
Rationale: A glomerular filtration rate of 14 mL/min indicates severe kidney impairment and the need for hemodialysis. The other choices, such as BUN 16 mg/dL, serum magnesium 1.8 mg/dL, and serum phosphorus 4.0 mg/dL, are within normal ranges and do not directly indicate the need for hemodialysis in chronic kidney disease.