A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

aPTT

INR

WBC count

Answer and Explanation

The Correct Answer is A

A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.

B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.

C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.

D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.

B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.

A. Assess the apical pulse while the newborn is crying. B. Palpate the radial pulse for 30 seconds. C. Listen to the apical pulse while palpating the radial pulse. D. Auscultate the apical pulse at least 1 min.

Correct Answer is D

Explanation

A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.

B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.

C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.

D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.

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A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

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A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?