Nokea
A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?
- A. bleeding time
- B. platelet count
- C. activated PTT
- D. clotting time
Correct Answer: C
Rationale: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
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Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct Answer: B
Rationale: Sudden cessation of any medication, unless medically necessary, is ill-advised.
The nurse sees multiple items on the client's bedside table. Which items should the nurse remove because they pose a risk of infection for the client? Select all that apply.
- A. The menu from the client's last meal
- B. A glass of water without a cover
- C. An empty urinal that had been rinsed
- D. A sealed package of soda crackers
- E. A pitcher of water covered with a lid
- F. A bloody alcohol swab from an injection
Correct Answer: B,C,F
Rationale: B: Uncovered water can become contaminated over time. C: A rinsed urinal may still harbor microorganisms. F: A bloody swab is a biohazard and can transmit pathogens. A, D, E are safe as they are either non-contaminable or properly sealed.
The client's total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result?
- A. Respiratory rate slow and shallow
- B. Skin incision pink, crusty, and intact
- C. Dark amber urine per urinary catheter
- D. Diminished lung sounds with crackles
Correct Answer: D
Rationale: D: Elevated WBC and crackles suggest a respiratory infection. A: Slow respiration is unrelated. B: Normal incision appearance doesn't correlate. C: Amber urine indicates dehydration, not infection.
The provider order reads 'Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?
- A. Hold the tube feeding and notify the provider
- B. Administer the tube feeding as scheduled
- C. Irrigate the tube with diet cola soda
- D. Apply intermittent suction to the feeding tube
Correct Answer: A
Rationale: Hold the tube feeding and notify the provider. A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.
The new nurse is caring for the client with a VRE infection. Which statement to the client indicates the new nurse needs additional orientation when caring for clients with a VRE infection?
- A. "All hospital staff should be wearing gown and gloves when they enter your room."
- B. "Visitors should use soap and water for hand washing when entering and leaving your room."
- C. "You are in a private room because VRE is transmitted by direct and indirect contact."
- D. "VRE is a new strain of enterococci bacteria normally found in a person's GI tract."
Correct Answer: A
Rationale: A: Gowns are only needed if clothing contamination is likely, indicating a need for further training. B, C, D: These statements are correct.