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A nurse is caring for a client who has a new prescription for heparin. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Heparin's anticoagulant effect is monitored via PTT to ensure therapeutic dosing. Potassium, hemoglobin, or BUN aren't directly affected by heparin.
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A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 4 hr.
- B. Flush the tube with water every 12 hr.
- C. Position the client supine during feeding.
- D. Change the feeding bag every 48 hr.
Correct Answer: A
Rationale: Checking residual volume every 4 hours assesses tolerance, preventing aspiration. Flushing is more frequent, supine positioning risks aspiration, and bags change every 24 hours.
A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid deep breathing exercises.
- C. Apply a warm compress to the incision site.
- D. Administer a sedative every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like thromboembolism. Deep breathing aids recovery, warm compresses risk infection, and sedatives aren't routine.
A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water every 4 hr.
- B. Place the client in a supine position during feeding.
- C. Check for gastric residual volume every 4 hr.
- D. Keep the head of the bed elevated to at least 30 degrees.
Correct Answer: D
Rationale: Elevating the bed to 30-45 degrees reduces aspiration risk by promoting proper digestion. Flushing maintains patency, supine position increases risk, and residual checks monitor tolerance.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.
- A. Wears a face mask around others
- B. Sleeps 8 to 10 hr per night
- C. Uses a firm bristled toothbrush
- D. Increased intake of green, leafy vegetables
Correct Answer: C
Rationale: A firm-bristled toothbrush risks gum bleeding in thrombocytopenia. Masks, sleep, or vegetables don't increase injury risk.