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A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.
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A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?
- A. Potassium chloride
- B. Calcium gluconate
- C. Magnesium sulfate
- D. Sodium bicarbonate
Correct Answer: B
Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.
An 82-year-old female client with type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. What should the nurse recommend?
- A. Seek routine nail care with a podiatrist.
- B. Encourage monthly pedicures at a nail salon.
- C. Soak feet for 10 minutes before cutting nails.
- D. Ask a family member to cut toenails.
Correct Answer: A
Rationale: For an 82-year-old female client with type 2 diabetes and degenerative arthritis, the nurse should recommend seeking routine nail care with a podiatrist. This is crucial to ensure proper and safe toenail care, reducing the risk of injury and infection, which is especially important for diabetic clients. Encouraging monthly pedicures at a nail salon (choice B) may not address the underlying issues related to diabetes and arthritis. Soaking feet for 10 minutes before cutting nails (choice C) may help soften the nails but does not address the difficulty the client faces in cutting them. Asking a family member to cut toenails (choice D) may not guarantee the expertise needed for proper diabetic foot care, which a podiatrist can provide.
What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?
- A. A history of diarrhea following each feeding
- B. Gastric pain evidenced by vigorous crying
- C. Poor appetite due to a poor sucking reflex
- D. An olive-shaped mass right of the midline
Correct Answer: D
Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.
What should be included in the therapeutic management of iron deficiency anemia?
- A. Multivitamins
- B. Calcium
- C. Ferrous sulfate
- D. Iodine
Correct Answer: C
Rationale: The correct answer is C: Ferrous sulfate. The therapeutic management of iron deficiency anemia should include iron supplementation, specifically with ferrous sulfate. This helps to replenish the body's iron stores. Multivitamins (choice A) may contain iron, but iron supplementation is more direct and effective. Calcium (choice B) and iodine (choice D) are not typically part of the primary treatment for iron deficiency anemia.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.