Nokea
The nurse is administering heparin to a client with a DVT. Which laboratory value should the nurse monitor closely?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Red blood cell count
Correct Answer: B
Rationale: Heparin's anticoagulant effect is monitored using aPTT to ensure therapeutic dosing and prevent bleeding.
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The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Teach the client how to perform a glucometer check.
- B. Assist feeding the client diagnosed with congestive heart failure.
- C. Check the cholesterol level for the client diagnosed with atherosclerosis.
- D. Assist the nurse to check the unit of blood at the client's bedside.
Correct Answer: B
Rationale: Feeding a CHF client (B) is within UAP scope and safe. Teaching glucometer (A), checking cholesterol (C), and blood verification (D) require nursing judgment.
The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, 'What is the worst thing that could happen if I don’t quit smoking? I love my cigarettes.' Which statement is the nurse’s best response?
- A. You are concerned about quitting smoking. Let’s sit down and talk about it.'
- B. Many clients end up having to have an amputation, especially a leg.'
- C. You should consider attending a smoking cessation program.'
- D. Your coronary arteries could block and cause a heart attack.'
Correct Answer: B
Rationale: Smoking worsens Buerger’s, risking severe ischemia and amputation (B). Concern (A) avoids the question, cessation programs (C) are secondary, and heart attack (D) is less specific.
Which teaching point should the nurse include for a client with peripheral artery disease? Select all that apply.
- A. Inspect feet daily for sores or injuries.
- B. Wear tight shoes to support the feet.
- C. Stop smoking to improve blood flow.
- D. Exercise until pain occurs, then rest.
- E. Apply lotion to dry skin on legs.
- F. Avoid crossing legs when sitting.
Correct Answer: A,C,D,E,F
Rationale: Inspecting feet, stopping smoking, exercising with rest, applying lotion, and avoiding leg crossing promote circulation and prevent complications in peripheral artery disease.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
Which dietary recommendation should the nurse provide to a client with hypertension?
- A. Follow the DASH diet.
- B. Increase red meat consumption.
- C. Drink caffeinated beverages daily.
- D. Use table salt liberally.
Correct Answer: A
Rationale: The DASH diet, rich in fruits, vegetables, and low-fat dairy, is proven to lower blood pressure.