Nokea
A client is receiving heparin therapy for a pulmonary embolism. The nurse should monitor the client for which of the following adverse effects?
- A. Thrombocytopenia.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Heparin can cause heparin-induced thrombocytopenia, a serious adverse effect that reduces platelet count and increases clotting risk, requiring close monitoring.
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One of the primary purposes of a formal medication reconciliation is to:
- A. Prevent polypharmacy
- B. Conserve financial resources
- C. Prevent interactions
- D. Prevent allergies
Correct Answer: C
Rationale: Medication reconciliation compares current and previous medication lists to identify and prevent potential drug interactions, ensuring safe prescribing.
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
- A. Refuses to look at the dressing
- B. Requires help with sponge bathing
- C. Asks that the nurse limit visitors to only family
- D. Dresses in a loose nightgown the client brought from home
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
- A. Fatigue
- B. Dyspnea
- C. Bradycardia
- D. Muscle cramps
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
The nurse fails to recognize that a client's vital signs have deteriorated over the past 4 hours after surgery. Later, the client requires emergency surgery. Which legal consequence does the nurse potentially face because of a failure to act?
- A. Tort
- B. Statutory law
- C. Common law
- D. Misdemeanor
Correct Answer: A
Rationale: The nurse's inaction is consistent with a tort offense because a tort is a wrongful act intentionally or unintentionally committed against a person or the person's property. Option 2 describes laws that are enacted by state, federal, or local governments. Option 3 describes case law that has evolved over time via precedents. Option 4 is an offense under criminal law.
A client is taking ciprofloxacin (Cipro). Which of the following laboratory studies will not be affected by ciprofloxacin?
- A. Theophylline level.
- B. Prothrombin time (PT).
- C. Partial thromboplastin time (PTT).
- D. Total iron-binding capacity.
Correct Answer: D
Rationale: Ciprofloxacin does not typically affect total iron-binding capacity, unlike theophylline levels (drug interaction) or coagulation studies (PT/PTT).