N487 Leadership in Nursing: NCLEX Quiz Ch 18-22
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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 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
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
Exam fully solved & updated 2025-2026(latest
version verified for accuracy) (Questions +
Answers) Solved 100% Correct!!
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 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
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
