Nokea
A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation?
- A. Prothrombin time (PT) or international normalized ratio (INR)
- B. Hourly IV infusion
- C. Vascular sites for bleeding
- D. Urine output
Correct Answer: A
Rationale: The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.
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Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?
- A. Acute Pain
- B. Coping Impairment
- C. ADL Deficit
- D. Activity Intolerance
Correct Answer: A
Rationale: The hallmark symptom of Raynaud syndrome is acute pain related to the arterial insufficiency. ADL Deficit, Coping Impairment, and Activity Intolerance can occur but are less significant than Acute Pain.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?
- A. Everything will be fine. Your family is here for you
- B. Don't cry; you have the best team of doctors
- C. Would you like something to calm your nerves?
- D. Tell me what concerns you most
Correct Answer: D
Rationale: Allowing the client to share feelings tends to relieve or reduce emotional distress. Telling a client that everything is fine negates the feelings they are expressing. Telling a client not to cry can be viewed as insensitive to the feelings being expressed. Providing a prescribed sedative may be helpful but does not address the fears and concerns of the client.
Clients taking vasodilator drugs have a greater risk for postprandial hypotension. Which of the following is the best nursing explanation for this phenomenon?
- A. Gravity pulls blood to the lower extremities while sitting
- B. Blood is being diverted to the gastrointestinal tract
- C. Decreased peripheral blood flow results
- D. Bronchospasms are increased when food enters the stomach
Correct Answer: B
Rationale: During digestion, blood is diverted to the GI tract which decreases cerebral blood flow and increases potential of orthostatic hypotension. Although gravity does pull blood to the lower extremities while sitting, this is not the primary concern with postprandial hypotension. Decreased peripheral blood flow does not result in postprandial hypotension. Bronchospasms are associated more with asthma not diversion of blood flow.
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?
- A. Assess the client's mental and emotional status
- B. Assess the skin of the client
- C. Assess the characteristics of chest pain
- D. Assess for any kind of drug abuse
Correct Answer: C
Rationale: The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
- A. Examine the client's mental and emotional status
- B. Examine the legs for color, capillary refill time, and tissue integrity
- C. Examine for pain around the shoulder and neck region
- D. Examine the extremities for skin lesions
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.