Nokea
A client is admitted to the unit with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and I.V. heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
- A. Administering aspirin as ordered
- B. Encouraging green leafy vegetables in the diet
- C. Monitoring the client's prothrombin time (PT)
- D. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR)
Correct Answer: D
Rationale: Heparin therapy for DVT requires monitoring aPTT to ensure therapeutic anticoagulation (1.5–2.5 times baseline). INR is less relevant for heparin but may be monitored if transitioning to warfarin. Aspirin is not typically used, and green leafy vegetables (high in vitamin K) may affect warfarin, not heparin.
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A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse's best response?
- A. œThe drainage tube is used to prevent infection in the peritoneal cavity.'
- B. œThe drainage tube is used to prevent bleeding into the peritoneal cavity.'
- C. œThe drainage tube is used to prevent pressure on on the bladder.'
- D. œThe drainage tube is used to prevent pressure on the gallbladder.'
Correct Answer: A
Rationale: A Jackson-Pratt drain removes fluid and blood from the surgical site, preventing infection in the peritoneal cavity by reducing fluid accumulation post-diverticulum repair.
A client is scheduled for a renal ultrasound. The nurse explains that:
- A. Contrast dye is used.
- B. No preparation is needed.
- C. Fasting is required.
- D. A sedative is given.
Correct Answer: B
Rationale: Renal ultrasound is non-invasive and requires no special preparation.
The nurse should remind family members who are visiting a client with granulocytopenia to:
- A. Visit only if they do not have a cold.
- B. Wash their hands.
- C. Leave the children at home.
- D. Avoid kissing the client on the lips.
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent transmission of pathogens to a granulocytopenic client, who is at high risk for infection. While avoiding colds, leaving children at home, and avoiding kissing are helpful, hand washing is the priority.
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?
- A. I can use heat and cold as often as I want.'
- B. With heat, I should apply it for no longer than 20 minutes at a time.'
- C. Heat-producing liniments can be used with other heat devices.'
- D. Ten to 15 minutes per application is the maximum time for cold applications.'
Correct Answer: A
Rationale: Frequent or prolonged use of heat and cold without guidance can cause tissue damage. The other statements reflect appropriate understanding of time limits and safe use.