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National Council Licensure Examination - NCLEX-RN Questions 193–195 (page: 79)

Updated On: 9-Feb-2026

A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?

  1. Partial thromboplastin time
  2. Hemoglobin
  3. Red blood cell (RBC) count
  4. Prothrombin time

Answer(s): A

Explanation:

(A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. (B) Hemoglobin is the main component of RBCs. Its main function is to carry O2from the lungs to the body tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor the effects of oral anticoagulants, e.g., coumarintype anticoagulants.



A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

  1. Below the umbilicus toward left side of mother's abdomen
  2. Below the umbilicus toward right side of mother's abdomen
  3. At the umbilicus
  4. Above the umbilicus to the left side of mother's abdomen

Answer(s): A

Explanation:

(A) LOA identifies a fetus whose back is on its mother's left side, whose head is the presenting part, and whose back is toward its mother's anterior. It is easiest to auscultate fetal heart tones (FHTs) through the
fetus's back. (B) The identified fetus's back is on its mother's left side, not right side. It is easiest to auscultate FHTs through the fetus's back. (C) In an LOA position, the fetus's head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus's heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.



A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

  1. Below the umbilicus toward left side of mother's abdomen
  2. Below the umbilicus toward right side of mother's abdomen
  3. At the umbilicus
  4. Above the umbilicus to the left side of mother's abdomen

Answer(s): A

Explanation:

(A) LOA identifies a fetus whose back is on its mother's left side, whose head is the presenting part, and whose back is toward its mother's anterior. It is easiest to auscultate fetal heart tones (FHTs) through the
fetus's back. (B) The identified fetus's back is on its mother's left side, not right side. It is easiest to auscultate FHTs through the fetus's back. (C) In an LOA position, the fetus's head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus's heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.



When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?

  1. "I will not eat any raw or uncooked vegetables."
  2. "I will limit my alcohol to one cocktail per day."
  3. "I will look into attending Alcoholics Anonymous meetings."
  4. "I will report any changes in bowel movements to my doctor."

Answer(s): C

Explanation:

(A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.



When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?

  1. "I will not eat any raw or uncooked vegetables."
  2. "I will limit my alcohol to one cocktail per day."
  3. "I will look into attending Alcoholics Anonymous meetings."
  4. "I will report any changes in bowel movements to my doctor."

Answer(s): C

Explanation:

(A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.



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