Extract:

Question 1 of 5

A nurse is assisting with the care of a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

A. Monitor the client's aPTT every 12 hr.B. Change the IV site every 24 hr.C. Administer the infusion at a rate of 50 mL/hr.D. Flush the IV line with dextrose 5% in water every 4 hr.

Correct Answer: A

Rationale: Heparin requires aPTT monitoring (e.g., every 6-12 hr) to ensure therapeutic levels. Site changes are less frequent, rate depends on orders, and saline is used, not dextrose.

Question 2 of 5

A nurse is reinforcing teaching with a client who has a new prescription for apixaban. Which of the following statements should the nurse include?

A. You should take this medication on an empty stomach.B. You might notice an increase in your bruising.C. This medication might cause your urine to turn orange.D. You should avoid drinking alcohol while taking this medication.

Correct Answer: B

Rationale: Apixaban, an anticoagulant, increases bleeding risk, leading to bruising. It's taken with or without food, urine color isn't affected, and alcohol isn't contraindicated but should be limited.

Extract:

Nurses' Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Question 3 of 5

A nurse is caring for a newly admitted older adult client. Nurses' Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' Which of the following interventions should the nurse recommend to include in the client's plan of care? Select all that apply.

A. Tell the client's child that they will be reported for maltreatment of the client.B. Ask the client's child to provide details regarding the client's fractured arm.C. Discuss respite care options with the client's child.D. Speak to the client privately.E. Provide legal advice to the client regarding power of attorney.

Correct Answer: B,C,D

Rationale: Asking for details about the fracture gathers information, discussing respite care supports the caregiver, and speaking privately assesses for abuse safely. Threatening reporting lacks evidence, and legal advice is outside nursing scope.

Extract:

Question 4 of 5

A nurse is assisting with the care of a client who is at risk for falls. Which of the following actions should the nurse take?

A. Keep the client's bed in the highest position.B. Ensure the client wears socks while ambulating.C. Place a fall risk identification band on the client's wrist.D. Instruct the client to call for assistance before getting out of bed.

Correct Answer: D

Rationale: Calling for assistance reduces fall risk by ensuring support. High beds, socks only, and no band alone increase risk without addressing immediate safety.

Question 5 of 5

A nurse is caring for a client who has a prescription for ketorolac IV. Which of the following actions should the nurse take?

A. Administer the medication over 5 minutes.B. Monitor the client for signs of gastrointestinal bleeding.C. Dilute the medication in dextrose 5% in water.D. Check the client's blood pressure prior to administration.

Correct Answer: B

Rationale: Ketorolac risks GI bleeding, requiring monitoring (e.g., melena). It's given over 15-30 seconds, diluted in saline, and BP isn't primary.