Nokea
A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?
- A. Prothrombin time (PT)
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
Correct Answer: C
Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.
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Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?
- A. Reduced cardiac output
- B. Disrupted surfactant production
- C. Hyperactivity of alveoli
- D. Increased oxygen carrying capacity
Correct Answer: B
Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.
After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?
- A. Monitor the client's potassium level.
- B. Assess the client's blood pressure.
- C. Check the client's hemoglobin and hematocrit levels.
- D. Monitor for signs of infection.
Correct Answer: A
Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.
The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?
- A. Maintain a closed drainage system
- B. Cleanse the catheter insertion site daily
- C. Increase the client's fluid intake
- D. Empty the collection bag every 4 hours
Correct Answer: A
Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.
A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?
- A. Monitor the client's liver function tests.
- B. Monitor the client's prothrombin time (PT).
- C. Monitor the client's partial thromboplastin time (PTT).
- D. Monitor the client's red blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.
An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
- A. Perform a 12-lead electrocardiogram
- B. Document in the client's record
- C. Notify the healthcare provider immediately
- D. Assess for signs of heart failure
Correct Answer: B
Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.