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A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?
- A. aPTT 75 seconds.
- B. INR 1.2.
- C. Hemoglobin 10 g/dL.
- D. Fibrinogen level 350 mg/dL.
Correct Answer: A
Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.
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A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.
A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administering the medication.
- B. Insert the needle at a 45° angle.
- C. Use a Z-track technique to administer the injection.
- D. Aspirate for blood before injecting the medication.
Correct Answer: C
Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.
A nurse is providing discharge teaching to a client with type 2 diabetes mellitus. Which of the following resources should the nurse provide?
- A. Personal blogs about managing diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct Answer: D
Rationale: The correct answer is D. Food exchange lists are valuable resources for individuals with diabetes as they provide structured meal planning guidance. This helps individuals manage their diabetes effectively by controlling their carbohydrate intake. Choices A, B, and C are incorrect because personal blogs may not provide reliable and evidence-based information, food label recommendations from the Institute of Medicine may not be specific for diabetes meal planning, and diabetes medication information from the Physicians' Desk Reference is not directly related to meal planning for diabetes management.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?
- A. Clamp the chest tube during ambulation
- B. Keep the collection chamber below the level of the chest
- C. Add sterile water to the water-seal chamber
- D. Empty the collection chamber every 12 hours
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.