Nokea
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
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The nurse is caring for a client who has just undergone a nephrectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor urine output.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: A
Rationale: Monitoring urine output is critical post-nephrectomy to assess the function of the remaining kidney.
Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
- A. 3,4,2,1,5,6
- B. 3,4,5,1,2,6
- C. 2,3,5,1,4,6
- D. 3,2,4,1,5,6
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
A 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which of the following? Select all that apply.
- A. Refer client to a nutritionist for the following day.
- B. Ensure that the client has a prescription for an antiemetic.
- C. Ask the health care provider (HCP) for an anxiolytic prescription.
- D. Encourage return to normal routine when client feels ready.
- E. Coordinate follow-up appointment with provider in 6 weeks.
- F. Discuss plan of care and discharge instructions with client.
Correct Answer: A, B, D, F
Rationale: For hyperemesis gravidarum, a nutritionist referral, antiemetic prescription, gradual return to routine, and discussing discharge instructions are essential. Anxiolytics may not be indicated, and a 6-week follow-up is too delayed.
A client is prescribed risperidone. Which laboratory study should the nurse anticipate to be prescribed before the initiation of this medication therapy?
- A. Platelet count
- B. Blood clotting tests
- C. Liver function studies
- D. Complete blood count
Correct Answer: C
Rationale: Risperidone is an atypical antipsychotic medication that suppresses behavioral response in psychosis. Baseline assessment includes renal and liver function tests, and these studies should be done before the initiation of treatment. This medication is used with caution in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients. None of the other options are related to the administration of this medication.