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A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum potassium
- B. Platelets
- C. aPTT
- D. INR
Correct Answer: C
Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.
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A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 110/70 mm Hg
- B. Temperature of 37.2°C (99°F)
- C. Serosanguineous wound drainage
- D. Bile-colored drainage from the surgical site
Correct Answer: D
Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.
How should a healthcare provider care for a patient with a tracheostomy?
- A. Clean the tracheostomy site daily
- B. Change the tracheostomy ties daily
- C. Suction the tracheostomy regularly
- D. Provide humidified oxygen
Correct Answer: C
Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?
- A. Increased urine output
- B. Increased serum sodium
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: C
Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.
A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?
- A. Dry, hacking cough
- B. Bounding peripheral pulses
- C. Decreased urinary output
- D. Weight loss of 1 kg in 24 hours
Correct Answer: C
Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.
A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?
- A. Take one puff every 5 minutes until symptoms improve.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Shake the inhaler for 2 seconds before use.
- D. Exhale forcefully after each puff.
Correct Answer: B
Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.