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.
You may also like to solve these questions
The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?
- A. Wipe up the stool with toilet paper and then clean the area with soap and water
- B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution
- C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket
- D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool
Correct Answer: B
Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.
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.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.
The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
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.