1. Discontinue the heparin infusion.
2. Slow down the heparin infusion.
3. Check the prothrombin time (PT) results.
4. Continue to monitor the client.
Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer.
(1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range
(2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range
(3) prothrombin time (PT) test is useful for assessing warfarin (Coumadin) therapy
(4) correct—expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
1029. The homecare nurse is visiting an elderly client with osteoarthritis. It would be MOST important for the nurse to include which of the following instructions?
1. “Swimming is the only helpful exercise for osteoarthritis.”
2. “Warm-up exercises should be done prior to exercising.”
3. “Exercises should be done routinely, even if severe joint pain occurs.”
4. “Isometric exercises are most helpful to prevent contractures.”
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) swimming is only one helpful exercise
(2) correct—warm-up or “stretching” exercises should always be done to begin and end exercising
(3) severely painful joints should not be exercised
(4) isometric exercises do not involve joint movement NCLEX Question Trainer
1030. The nurse observes a new graduate nurse palpating the uterine contractions of a 21-year-old primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is MOST appropriate?
1. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
2. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
3. The graduate nurse places one hand on the abdomen over the fundus and with the fingertips, presses gently.
4. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
Strategy: “MOST appropriate” indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) palpations should be done with fingertips, not palms of hands
(2) palpations should be done with fingertips, not heels of hands
(3) correct—done with fingertips
(4) palpations should be done with fingertips, not palms of hands