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A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. International Normalized Ratio (INR)
- B. Prothrombin time (PT)
- C. Serum sodium level
- D. Hemoglobin level of 12 g/dl
Correct Answer: A
Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range to prevent both bleeding and clotting events. Choices B, C, and D are incorrect because while PT is used to monitor warfarin therapy, INR is a more precise indicator of therapeutic levels. Serum sodium level and hemoglobin level are not directly related to monitoring warfarin therapy.
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In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
- A. Note the appearance and patency of the client's peripheral IV site.
- B. Palpate the volume of the client's right radial pulse.
- C. Auscultate the client's breath sounds bilaterally.
- D. Observe the amount and dose of morphine in the PCA pump syringe.
Correct Answer: D
Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Watery diarrhea
- B. Nausea
- C. Headache
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.
The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?
- A. Pupils reactive to accommodation.
- B. Nystagmus present with pupillary focus.
- C. Peripheral vision intact.
- D. Consensual pupillary constriction present.
Correct Answer: A
Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.
A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?
- A. Decreased bowel sounds
- B. Increased heart rate
- C. Decreased urine output
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.
The nurse is assessing a client with left-sided heart failure. Which finding should be reported to the healthcare provider immediately?
- A. Shortness of breath
- B. Jugular venous distention
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with left-sided heart failure, the presence of crackles in the lungs is the most critical finding that should be reported to the healthcare provider immediately. Crackles indicate pulmonary congestion, which requires prompt intervention to prevent respiratory compromise. Shortness of breath, though a common symptom in heart failure, is a result of pulmonary congestion, making crackles a more direct indicator of the severity of the condition. Jugular venous distention and elevated liver enzymes are important to assess in heart failure but are not as immediately concerning as crackles in the lungs, which directly reflect the impact of heart failure on the respiratory system.