Questions 158

NCLEX-RN

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Question 1 of 5

A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?

Correct Answer: A

Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.

Question 2 of 5

A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

Correct Answer: A

Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.

Question 3 of 5

The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?

Correct Answer: A

Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being.
Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.

Question 4 of 5

The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

Correct Answer: A

Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.

Question 5 of 5

The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?

Question Image

Correct Answer: A, B, C

Rationale: West Nile virus is transmitted by mosquitoes (
A), blood transfusions (
B), and organ transplants (
C). Birds (
D) and horses (E) are hosts but not direct vectors to humans.

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