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A nurse Is evaluating the laboratory results of four clents. The nurse should report which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- C. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
- D. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A client with a prescription for heparin and an aPTT of 90 seconds indicates that the client's blood is taking too long to clot, which puts the client at risk for bleeding. The aPTT range for a client on heparin therapy is 30-40 seconds, so a result of 90 seconds is significantly elevated and requires immediate attention to prevent bleeding complications.
Summary of other choices:
B: A client with a prescription for heparin and an aPTT of 65 seconds falls within the normal range of 30-40 seconds, so this result does not require immediate reporting.
C: A client with a prescription for warfarin and an INR of 3.0 is within the therapeutic range (2-3) for warfarin therapy, so this result does not require immediate reporting.
D: A client with a prescription for warfarin and an INR of 2.0 is also
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A nurse is assessing for allergies with a client who is scheduled to receive the influenza vaccine. Which of the following allergies should the nurse report to the provider as a possible contraindication to receiving the vaccine?
- A. Eggs
- B. Shellfish
- C. Peanuts
- D. Milk
Correct Answer: A
Rationale: The correct answer is A: Eggs. Influenza vaccines are typically produced using eggs, so individuals with egg allergies may have an allergic reaction to the vaccine. Reporting this allergy to the provider is crucial to avoid potential adverse reactions. Shellfish, peanuts, and milk allergies are not contraindications for receiving the influenza vaccine. Summary: Eggs are the correct answer due to the vaccine production method; shellfish, peanuts, and milk allergies are not relevant in this context.
A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first?
- A. Encourage the client to dangle the legs while sitting in a chair
- B. Teach the client about foods low in sodium
- C. Determine medication adherence by the client
- D. Notify the provider of the client's weight gain
Correct Answer: D
Rationale: The correct answer is D: Notify the provider of the client's weight gain. This is the first action the nurse should take because sudden weight gain in a client with heart failure could indicate fluid retention, which may worsen the client's condition. By notifying the provider, the nurse can ensure timely intervention to adjust the medication or treatment plan. Encouraging leg dangling (A) may help with circulation but does not address the immediate concern of weight gain. Teaching about low-sodium foods (B) is important for long-term management but not the priority at this moment. Determining medication adherence (C) is important but should come after addressing the immediate weight gain issue.
A nurse is caring for a client in a provider's office. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea, so take with a meal
- B. You can experience vivid nightmares."
- C. You may notice your urine becomes lighter in color
- D. Consumption of a high protein meal can reduce the effectiveness of the medication
- E. You may initially notice an increase in involuntary movements
- F. This medication can make you light-headed if you stand up too quickly from a seated or lying position
Correct Answer: A, B, E, F
Rationale: Correct Answer: A, B, E, F
Rationale:
A: Taking the medication with a meal can help reduce nausea, enhancing tolerance.
B: Mentioning vivid nightmares prepares the client for a potential side effect.
E: Increase in involuntary movements is a common side effect of certain medications.
F: Informing about potential dizziness upon standing up quickly promotes safety.
These statements address medication effects and side effects, promoting client understanding and safety.
Incorrect Choices:
C: Urine color change may not be relevant to the medication being discussed.
D: High protein meal interaction is not mentioned for this medication.
Incorrect choices lack relevance or do not address potential medication effects, making them not suitable for client education.
A nurse is caring for a client who has a respiratory infection and is receiving an antibiotic. Which of the following medications puts the client at risk for developing hearing loss?
- A. Rifampin
- B. Ciprofloxacin
- C. Penicillin G
- D. Gentamicin
Correct Answer: D
Rationale: The correct answer is D: Gentamicin. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, leading to hearing loss. The medication affects the inner ear's hair cells, resulting in irreversible damage. Rifampin (A), Ciprofloxacin (B), and Penicillin G (C) are not associated with ototoxicity. In summary, Gentamicin (D) is the only medication in the choices that poses a risk for hearing loss due to its ototoxic effects on the inner ear.
A nurse is assessing a client following the administration of ondansetron (Zofran). Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is primarily used to treat nausea and vomiting. If the client reports a decrease in nausea, it indicates that the medication has been effective in managing this specific symptom. Decrease in pain (choice A) is not directly related to the action of ondansetron. Choices C (decrease in coughing) and D (decrease in diarrhea) are not typical indications of ondansetron's effectiveness. It is important for the nurse to focus on the specific expected outcome of the medication, which is the reduction of nausea and vomiting.