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The nurse is evaluating clients for risk of heparin-induced thrombocytopenia (HIT). Which client is at greatest risk for HIT, based on the nurse's assessment?
- A. a male client who just completed a 1-week course of heparin
- B. a male client taking enoxaparin for management of unstable angina
- C. a female client receiving heparin for postsurgical thromboprophylaxis
- D. a female client taking enoxaparin to prevent clots following a mild myocardial infarction
Correct Answer: C
Rationale: Unfractionated heparin (C) carries a higher HIT risk than enoxaparin, especially in postoperative settings due to prolonged exposure.
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The nurse is caring for a client who is undergoing a pharmacological stress test because she cannot use the treadmill. The nurse administers the prescribed dose of adenosine. Which physiological response indicates an adverse effect of the adenosine requiring intervention by the nurse? Select all that apply.
- A. nausea
- B. RR of 18
- C. HR of 97
- D. chest pain
- E. facial flushing
Correct Answer: D
Rationale: Chest pain (D) indicates a potential adverse effect of adenosine, such as coronary ischemia, requiring intervention. Nausea and flushing are common, and RR 18 and HR 97 are normal.
The nurse is educating a client newly diagnosed with gout regarding dietary choices. The nurse understands that further teaching is needed if the client orders which foods for lunch?
- A. fruit cup with corn bread and tea
- B. tuna fish sandwich with green peas
- C. a peanut butter sandwich with 1 percent milk
- D. low-fat cheese and crackers with blueberries
Correct Answer: B
Rationale: Tuna is high in purines, which exacerbate gout, indicating a need for further teaching. Other options are low-purine and appropriate.
The nurse is caring for a client who has just returned from the cardiac catheterization lab. Which complications of cardiac catheterization require immediate intervention by the nurse? Select all that apply.
- A. chest pain
- B. decreased appetite
- C. difficulty swallowing
- D. hematoma formation
- E. decreased pulses in the affected extremity
Correct Answer: A,D,E
Rationale: Chest pain (A), hematoma (D), and decreased pulses (E) indicate potential complications like myocardial ischemia, bleeding, or arterial occlusion, requiring immediate intervention.
A client is admitted to the ED after complaining of acute chest pain radiating down the left arm. The client is diaphoretic and anxious, and has difficulty breathing. Which laboratory studies would the nurse anticipate?
- A. blood urea nitrogen (BUN)
- B. white blood cell count
- C. LDH
- D. myoglobin
Correct Answer: D
Rationale: Chest pain radiating to the left arm, diaphoresis, and dyspnea suggest myocardial infarction. Myoglobin (D) is an early cardiac marker. BUN (A) assesses kidneys, WBC (B) assesses infection, and LDH (C) is less specific.
The nurse is caring for a client with seizure disorder. Which statement regarding seizure precautions is correct?
- A. Padded tongue blades should be at the bedside.
- B. Oxygen and suctioning should be at the bedside.
- C. Padding bed rails with blankets can help prevent injury.
- D. Restraint mitts will help keep the client from removing tubes or IVs.
Correct Answer: B,C
Rationale: Oxygen and suctioning (B) ensure airway management, and padded bed rails (C) prevent injury during seizures. Padded tongue blades (A) are unsafe, and restraints (D) are not standard seizure precautions.