Nokea
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client states the drug is dangerous. What action by the nurse is best?
- A. Assess the reason behind the client's fear
- B. Remind the client about laboratory monitoring
- C. Tell the client drugs are safer today than before
- D. Warn the client about consequences of noncompliance
Correct Answer: A
Rationale: The first step is to assess the reason behind the client's fear, which may be related to a past experience. Addressing the specific concern is critical for effective teaching and compliance. The other options do not address the client's fear directly.
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A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
- A. Assess the client's neurological status
- B. Notify the Rapid Response Team
- C. Prepare to administer vitamin K
- D. Turn down the infusion rate
Correct Answer: B
Rationale: Clients on fibrinolytic therapy are at high risk of bleeding. Sudden neurologic signs may indicate a hemorrhagic stroke. The nurse should first call the Rapid Response Team based on the client's manifestations, then perform a thorough neurological examination.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
A nurse is caring for a client on IV infusion of heparin. What actions does the nurse include in the client's plan? (Select all that apply.)
- A. Assess the client for bleeding
- B. Monitor the daily activated partial thromboplastin time (aPTT) results
- C. Stop the IV if aPTT shows baseline
- D. Use an IV pump for the infusion
- E. Weigh the client daily on the same scale
Correct Answer: A,B,D
Rationale: Assessing for bleeding, monitoring aPTT, and using an IV pump are critical for heparin safety. Stopping the IV at baseline aPTT is incorrect, as therapeutic levels are 1.5-2 times baseline. Weighing is not directly related.
Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)
- A. A good abrasive pumice stone will keep my feet soft
- B. I'll always wear shoes if I can buy cheap flip-flops
- C. I need to check my feet daily for sores
- D. Lotion is important to keep my feet smooth and soft
- E. Washing my feet in room-temperature water is best
Correct Answer: C,D,E
Rationale: Good foot care includes checking for sores, using lotion, and washing in room-temperature water to prevent injury. Abrasive pumice stones and flip-flops can cause harm due to decreased sensation in PVD.
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.