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A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
- A. Administer 50,000 units of heparin by IV bolus every 12 hours.
- B. Have vitamin K available on the nursing unit.
- C. Use tubing specific for heparin sodium when administering the infusion.
- D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
Correct Answer: D
Rationale: The correct answer is D: Check the activated partial thromboplastin time (aPTT) every 6 hours. This is crucial to monitor the therapeutic effect of heparin, ensuring the client's blood does not become too thin or too thick. Regular aPTT monitoring helps adjust the heparin infusion rate to maintain the desired anticoagulant effect.
Explanation of why other choices are incorrect:
A: Administering a large dose of heparin by IV bolus is dangerous and can lead to bleeding complications. Incorrect.
B: Having vitamin K available is not specifically related to managing heparin therapy. Incorrect.
C: Using tubing specific for heparin is important but is not the priority action in this scenario. Incorrect.
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A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
- A. Tamoxifen
- B. Leuprolide
- C. Finasteride
- D. Cyclophosphamide
Correct Answer: B
Rationale: The correct answer is B: Leuprolide. Leuprolide is a gonadotropin-releasing hormone agonist that suppresses testosterone production, which can help slow the growth of prostate cancer. Tamoxifen (A) is used for breast cancer, Finasteride (C) is used for benign prostatic hyperplasia, and Cyclophosphamide (D) is a chemotherapy drug for various cancers. Therefore, in this case, the most appropriate medication for prostate cancer would be Leuprolide (B).
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min. To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Flu-like symptoms and night sweats
- B. Fungal and bacterial infections
- C. Pneumocystis lung infection
- D. Kaposi’s sarcoma
Correct Answer: A
Rationale: The correct answer is A: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often present as flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This is known as acute retroviral syndrome and occurs within the first few weeks after exposure to the virus. These symptoms are nonspecific and can easily be mistaken for other common illnesses. Fungal and bacterial infections (B), Pneumocystis lung infection (C), and Kaposi’s sarcoma (D) are not initial symptoms of HIV infection. Fungal and bacterial infections typically occur in later stages of HIV when the immune system is severely compromised. Pneumocystis lung infection and Kaposi’s sarcoma are opportunistic infections seen in advanced stages of HIV, usually when the CD4 count is significantly low.
A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
- A. Chicken broth
- B. Flavored gelatin
- C. Cranberry juice
- D. Skim milk
Correct Answer: D
Rationale: The correct answer is D: Skim milk. Skim milk is allowed on a full liquid diet as it is easily digested and provides essential nutrients. It is also a good source of protein and calcium, important for healing post-surgery. Chicken broth (A) and flavored gelatin (B) are typically allowed on a clear liquid diet but may not be suitable for a full liquid diet. Cranberry juice (C) is acidic and may be too harsh on the stomach post-surgery. Therefore, the nurse should advise the client to choose skim milk for his meal tray to support healing and recovery.