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The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.
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A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
- A. Complain to her fellow nurses
- B. Wait until she knows more about the unit
- C. Discuss the problem with her supervisor
- D. Inform the staff that they must volunteer to rotate
Correct Answer: C
Rationale: In this scenario, the new head nurse should discuss the problem with her supervisor. This is the most appropriate action as the supervisor is in a position to address staffing concerns effectively and make necessary changes. Complaining to fellow nurses may not lead to a solution, waiting may exacerbate the issue, and demanding staff rotation without proper discussion is not a collaborative approach to resolving the problem.
When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?
- A. Discourage them from deciding until their grief has eased
- B. Listen to their concerns and answer their questions truthfully
- C. Urge them to immediately sign the consent form
- D. Inform them that the body will not be available for a wake or funeral
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert chronic arthritic patient treated with steroids and aspirin
- B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
- C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.
Which of the following scenarios represents nursing malpractice?
- A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and suffers cerebral damage due to anoxia.
- B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
- C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
- D. The nurse administers the wrong medication to a patient, resulting in vomiting. This error is documented and reported to the physician and the nursing supervisor.
Correct Answer: A
Rationale: The correct answer is A. Administering a drug to a patient with a known allergy, leading to severe harm such as an allergic reaction causing cerebral damage due to anoxia, constitutes nursing malpractice. In this scenario, the nurse failed to adhere to the standard of care by administering a medication that the patient was allergic to, resulting in serious harm, which is a clear example of malpractice in nursing.
A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the healthcare provider that the patient has bleeding from the GI tract?
- A. Complete blood count
- B. Guaiac test
- C. Vital signs
- D. Abdominal girth
Correct Answer: B
Rationale: A positive guaiac test is used to detect the presence of occult (hidden) blood in the stool, suggesting bleeding from the gastrointestinal tract. It is a rapid screening test that can provide immediate information to the healthcare provider about possible gastrointestinal bleeding in patients presenting with symptoms such as nausea, vomiting, diarrhea, and severe abdominal pain.