Nokea
A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Hemoglobin
- D. Platelet count
Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.
You may also like to solve these questions
Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?
- A. Check the client's blood pressure
- B. Monitor the client's heart rate
- C. Assess the client's respiratory rate
- D. Review the client's potassium level
Correct Answer: B
Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.
A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?
- A. Nausea and vomiting.
- B. Altered consciousness within the first 24 hours after injury.
- C. Severe headache and blurred vision.
- D. Loss of motor function on the affected side.
Correct Answer: B
Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.
After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?
- A. Monitor respiratory rate and rhythm.
- B. Assess for signs of hypocalcemia.
- C. Monitor for elevated body temperature.
- D. Check blood pressure every 30 minutes.
Correct Answer: B
Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.
A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?
- A. Apply lotion to the treatment area.
- B. Use mild soap and water to cleanse the area.
- C. Cover the area with a sterile dressing.
- D. Allow the skin to air dry after washing.
Correct Answer: B
Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.
A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?
- A. Ammonia level
- B. White blood cell count
- C. Albumin level
- D. Hemoglobin level
Correct Answer: A
Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.