N487 Leadership in Nursing: NCLEX Quiz
What is an important nursing action in the safe administration of heparin?
1. Check the prothrombin time (PT) and administer the medication if it is less than 20 seconds.
2. Use a 20-gauge, 1-inch (2.5 cm) needle and inject into the deltoid muscle and gently massage
the area.
3. Dilute in 50 mL 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over
15 minutes.
4. Use a 25-gauge, 1⁄2-inch (1.25 cm) needle and inject
the medication into the subcutaneous tissue of the abdomen. - Answer: 4
Medication should be administered with a small-gauge (25 gauge) needle into the subcutaneous
tissue without aspirating or massaging the area. Partial thromboplastin time (PTT) is used to
monitor
the effects of heparin. Although heparin may be administered IV, it must be diluted in more
than 50 mL D5W and would be administered over a longer period of time than 15 minutes.
(Lewis et al., 10th ed., p. 820)
While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to
have to take all of the medications that have been prescribed. On what principle is the nurse's
response based?
1. The client will be scheduled for an appointment in 2 months; the doctor will decrease her
medications at that time.
2. As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop
taking her medications.
3. To maintain stable control of her BP, the client will have to take the medications indefinitely.
4. The nurse cannot discuss the medications with the client; the client will need to talk with the
doctor. - Answer: 3
Noncompliance with blood pressure medications is a common problem in the treatment of
hypertension. The client must understand that the only way to keep her blood pressure under
control is to continue to take her medications, potentially for the rest of her life. She will not be
,N487 Leadership in Nursing: NCLEX Quiz
able to discontinue the medications unless there is a significant change in her condition as a
result of weight loss, an exercise program, and/or decreased stress. Patients usually require
follow-up and adjustments at monthly intervals until the
goal BP is reached. Antihypertensives control BP but do not cure hypertension, therefore the
medication cannot be stopped once the target reading is reached. (Ignatavicius & Workman, 8th
ed., pp. 712-713, 717-718)
The nurse is teaching a client about home care and treatment of venous stasis ulcers on his leg.
What should be included in the nurse's instructions? Select all that apply:
1. Dressings do not need to be changed frequently because there is minimal drainage.
2. Healing will be facilitated by wearing leg compression devices.
3. When the client is in the sitting position, he should keep his legs elevated.
4. Avoid standing for prolonged periods of time.
5. Cool packs can be applied to the ulcers to decrease inflammation.
6. Soak the affected extremity in warm water every evening. - Answer: 2, 3, 4
Healing of venous stasis ulcers is dependent on relieving the venous congestion in the
extremity. Compression devices and elevation of the extremity are the most effective methods.
The client should avoid standing for long periods because this increases venous stasis. Moist
cool and/or warm packs are not used, but moist environment dressings are utilized. Dressings
need to be changed as frequently as necessary because there may be excessive drainage.
(Ignatavicius & Workman, 8th ed., pp. 734-735)
The nurse is caring for a client who is 6 hours postpartum. What nursing actions are directed
toward the prevention of postpartum thrombophlebitis?
1. Encourage early ambulation and increased fluid intake.
2. Allow bathroom privileges only and elevate the lower extremities.
3. Administer anticoagulants and evaluate the clotting
,N487 Leadership in Nursing: NCLEX Quiz
factors.
4. Encourage the client to breastfeed the infant as soon as possible. - Answer: 1
Early ambulation is the most effective and safe way to prevent thrombophlebitis with any type
of client. This promotes venous return and prevents venous stasis. Anticoagulants (heparin and
warfarin) are administered as ordered postpartum with a diagnosis of thrombophlebitis; they
are not used for prevention. The legs should be elevated when the client is in a sitting position.
There is no evidence that breastfeeding affects blood coagulation in any way. (Ignatavicius &
Workman, 8th ed., pp. 730-731)
The nurse is preparing to administer spironolactone to a client. After assessing the client, what
data indicate the need to withhold the medication?
1. Potassium level of 5.8 mEq/L (mmol/L)
2. Apical pulse rate of 58 beats/min
3. BP of 130/90 mmHg
4. Urine output of 30 mL/hr - Answer: 1
Aldactone is a potassium-sparing diuretic. The client's potassium level is high; therefore the
medication should be held and the doctor should be notified. Urine output of 30 mL/hr is
normal output. The BP is elevated, which is the reason the client is receiving the medication.
The pulse rate is not affected by this medication. (Igntavicius & Workman, 8th ed., pp. 262, 712,
714)
Which nursing action would be most effective in preventing venous stasis in the postoperative
surgical client?
1. Raise the foot of the bed for 1 hour, then lower it to stimulate blood flow.
2. Massage the lower extremities every 6 hours.
3. Facilitate active range of motion of the upper body to stimulate cardiac output.
4. Help the client walk as soon as permitted and as often as possible. - Answer: 4
, N487 Leadership in Nursing: NCLEX Quiz
The postoperative client has decreased mobility, which may create an environment in which
clotting can be caused by venous stasis. Active exercise, such as having the client ambulate as
soon as possible, will stimulate circulation and venous return. This reduces the possibility of clot
formation. The lower extremities should not be massaged because this may disrupt a clot and
cause a pulmonary embolism. (Ignatavicius & Workman, 8th ed., pp. 730-731)
A client has had her blood pressure evaluated weekly for month. At the end of the month, the
nurse averages out the weekly blood pressures at 150/96 mmHg. The client is 20 pounds (9.1
kg) overweight, and her cholesterol is 240 mg/dL (6.22 mmol/L). What is important information
for the nurse to include in the teaching plan for this client?
1. Refer her to the doctor for further follow-up and medications.
2. Increase the fiber in her diet and begin a daily 30-minute
workout.
3. Reduce her sodium intake and decrease the dietary calories that come from fat.
4. Reduce her cholesterol intake for 1 month and check her BP 3 times a week. - Answer: 1
The client should be referred for further evaluation of blood pressure. The blood pressure is
definitely elevated, the client is overweight, and she has an increased level of cholesterol. A
multifocal approach is necessary to control the blood pressure. Because of the multiple risk
factors, increasing fiber in the diet and exercise would not likely be sufficient to reduce the
hypertension. Neither would dietary changes. This patient needs a multifocal approach.
(Ignatavicius & Workman, 8th ed., pp. 710-712)
Four hours after aortic-femoral bypass graft surgery, the nurse assesses the client and is unable
to palpate pulses in the operative leg. The client complains of pain in the leg. What is the first
nursing action?
1. Massage the leg and apply warm towels.
2. Elevate the leg and recheck the pulse.
3. Call the physician immediately.
What is an important nursing action in the safe administration of heparin?
1. Check the prothrombin time (PT) and administer the medication if it is less than 20 seconds.
2. Use a 20-gauge, 1-inch (2.5 cm) needle and inject into the deltoid muscle and gently massage
the area.
3. Dilute in 50 mL 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over
15 minutes.
4. Use a 25-gauge, 1⁄2-inch (1.25 cm) needle and inject
the medication into the subcutaneous tissue of the abdomen. - Answer: 4
Medication should be administered with a small-gauge (25 gauge) needle into the subcutaneous
tissue without aspirating or massaging the area. Partial thromboplastin time (PTT) is used to
monitor
the effects of heparin. Although heparin may be administered IV, it must be diluted in more
than 50 mL D5W and would be administered over a longer period of time than 15 minutes.
(Lewis et al., 10th ed., p. 820)
While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to
have to take all of the medications that have been prescribed. On what principle is the nurse's
response based?
1. The client will be scheduled for an appointment in 2 months; the doctor will decrease her
medications at that time.
2. As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop
taking her medications.
3. To maintain stable control of her BP, the client will have to take the medications indefinitely.
4. The nurse cannot discuss the medications with the client; the client will need to talk with the
doctor. - Answer: 3
Noncompliance with blood pressure medications is a common problem in the treatment of
hypertension. The client must understand that the only way to keep her blood pressure under
control is to continue to take her medications, potentially for the rest of her life. She will not be
,N487 Leadership in Nursing: NCLEX Quiz
able to discontinue the medications unless there is a significant change in her condition as a
result of weight loss, an exercise program, and/or decreased stress. Patients usually require
follow-up and adjustments at monthly intervals until the
goal BP is reached. Antihypertensives control BP but do not cure hypertension, therefore the
medication cannot be stopped once the target reading is reached. (Ignatavicius & Workman, 8th
ed., pp. 712-713, 717-718)
The nurse is teaching a client about home care and treatment of venous stasis ulcers on his leg.
What should be included in the nurse's instructions? Select all that apply:
1. Dressings do not need to be changed frequently because there is minimal drainage.
2. Healing will be facilitated by wearing leg compression devices.
3. When the client is in the sitting position, he should keep his legs elevated.
4. Avoid standing for prolonged periods of time.
5. Cool packs can be applied to the ulcers to decrease inflammation.
6. Soak the affected extremity in warm water every evening. - Answer: 2, 3, 4
Healing of venous stasis ulcers is dependent on relieving the venous congestion in the
extremity. Compression devices and elevation of the extremity are the most effective methods.
The client should avoid standing for long periods because this increases venous stasis. Moist
cool and/or warm packs are not used, but moist environment dressings are utilized. Dressings
need to be changed as frequently as necessary because there may be excessive drainage.
(Ignatavicius & Workman, 8th ed., pp. 734-735)
The nurse is caring for a client who is 6 hours postpartum. What nursing actions are directed
toward the prevention of postpartum thrombophlebitis?
1. Encourage early ambulation and increased fluid intake.
2. Allow bathroom privileges only and elevate the lower extremities.
3. Administer anticoagulants and evaluate the clotting
,N487 Leadership in Nursing: NCLEX Quiz
factors.
4. Encourage the client to breastfeed the infant as soon as possible. - Answer: 1
Early ambulation is the most effective and safe way to prevent thrombophlebitis with any type
of client. This promotes venous return and prevents venous stasis. Anticoagulants (heparin and
warfarin) are administered as ordered postpartum with a diagnosis of thrombophlebitis; they
are not used for prevention. The legs should be elevated when the client is in a sitting position.
There is no evidence that breastfeeding affects blood coagulation in any way. (Ignatavicius &
Workman, 8th ed., pp. 730-731)
The nurse is preparing to administer spironolactone to a client. After assessing the client, what
data indicate the need to withhold the medication?
1. Potassium level of 5.8 mEq/L (mmol/L)
2. Apical pulse rate of 58 beats/min
3. BP of 130/90 mmHg
4. Urine output of 30 mL/hr - Answer: 1
Aldactone is a potassium-sparing diuretic. The client's potassium level is high; therefore the
medication should be held and the doctor should be notified. Urine output of 30 mL/hr is
normal output. The BP is elevated, which is the reason the client is receiving the medication.
The pulse rate is not affected by this medication. (Igntavicius & Workman, 8th ed., pp. 262, 712,
714)
Which nursing action would be most effective in preventing venous stasis in the postoperative
surgical client?
1. Raise the foot of the bed for 1 hour, then lower it to stimulate blood flow.
2. Massage the lower extremities every 6 hours.
3. Facilitate active range of motion of the upper body to stimulate cardiac output.
4. Help the client walk as soon as permitted and as often as possible. - Answer: 4
, N487 Leadership in Nursing: NCLEX Quiz
The postoperative client has decreased mobility, which may create an environment in which
clotting can be caused by venous stasis. Active exercise, such as having the client ambulate as
soon as possible, will stimulate circulation and venous return. This reduces the possibility of clot
formation. The lower extremities should not be massaged because this may disrupt a clot and
cause a pulmonary embolism. (Ignatavicius & Workman, 8th ed., pp. 730-731)
A client has had her blood pressure evaluated weekly for month. At the end of the month, the
nurse averages out the weekly blood pressures at 150/96 mmHg. The client is 20 pounds (9.1
kg) overweight, and her cholesterol is 240 mg/dL (6.22 mmol/L). What is important information
for the nurse to include in the teaching plan for this client?
1. Refer her to the doctor for further follow-up and medications.
2. Increase the fiber in her diet and begin a daily 30-minute
workout.
3. Reduce her sodium intake and decrease the dietary calories that come from fat.
4. Reduce her cholesterol intake for 1 month and check her BP 3 times a week. - Answer: 1
The client should be referred for further evaluation of blood pressure. The blood pressure is
definitely elevated, the client is overweight, and she has an increased level of cholesterol. A
multifocal approach is necessary to control the blood pressure. Because of the multiple risk
factors, increasing fiber in the diet and exercise would not likely be sufficient to reduce the
hypertension. Neither would dietary changes. This patient needs a multifocal approach.
(Ignatavicius & Workman, 8th ed., pp. 710-712)
Four hours after aortic-femoral bypass graft surgery, the nurse assesses the client and is unable
to palpate pulses in the operative leg. The client complains of pain in the leg. What is the first
nursing action?
1. Massage the leg and apply warm towels.
2. Elevate the leg and recheck the pulse.
3. Call the physician immediately.
