A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?

Correct Answer: C

Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.

Correct Answer: A

Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.

Correct Answer: D

Rationale: The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well." This statement indicates a need for further teaching because shaking NPH insulin can cause denaturation and interfere with its proper action. Option A is correct because using a sliding scale to adjust insulin based on blood sugar levels is a common practice in managing diabetes. Option B is correct because visually impaired individuals may need assistance with filling syringes. Option C is correct because storing regular insulin in the refrigerator helps maintain its stability. From an educational perspective, this question highlights the importance of accurate insulin administration and storage practices in diabetes management. It emphasizes the need for nurses to educate clients on proper insulin techniques to ensure optimal therapeutic outcomes and prevent complications. Educating clients on insulin administration, storage, and safety measures is crucial in empowering them to effectively manage their diabetes and promote adherence to their treatment plan.

Correct Answer: C

Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.

Correct Answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.