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A client is receiving heparin therapy. Which laboratory value should be monitored by the nurse to evaluate the effectiveness of the therapy?
- A. PT
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is specifically used to monitor the effectiveness of heparin therapy. It should be maintained at 1.5 to 2 times the normal level. Monitoring aPTT helps ensure that the therapeutic range of heparin is achieved to prevent clot formation while minimizing the risk of bleeding complications.
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A client prescribed Warfarin is receiving discharge instructions from a nurse. Which of the following herbal supplements should the nurse instruct the client to avoid?
- A. St. John's wort
- B. Echinacea
- C. Garlic
- D. Ginseng
Correct Answer: A
Rationale: St. John's wort can reduce the effectiveness of Warfarin by interacting with its metabolism pathways, potentially leading to decreased anticoagulant effects. Therefore, clients on Warfarin therapy should avoid St. John's wort. While echinacea, garlic, and ginseng are also herbal supplements that can interact with Warfarin, St. John's wort is particularly known for its significant impact on Warfarin metabolism.
A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?
- A. Instruct the client to self-ambulate every 2 hours.
- B. Offer oral hygiene every 2 hours.
- C. Anticipate medication administration 2 hours prior to delivery.
- D. Monitor fetal heart rate every 2 hours.
Correct Answer: B
Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor.
A client has a new prescription for a Nitroglycerin transdermal patch. Which of the following instructions should the nurse include?
- A. Apply the patch to a different site each day.
- B. Remove the patch at bedtime each day.
- C. Apply the patch over an area with little or no hair.
- D. Keep the patch on for 24 hours at a time.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a new prescription for a Nitroglycerin transdermal patch for Angina Pectoris. Which of the following instructions should the nurse include?
- A. Remove the patch each evening.
- B. Do not cut the patch in half even if angina attacks are under control.
- C. Remove the nitroglycerin patch for 30 min if a headache occurs.
- D. Apply a new patch every 48 hours.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a new prescription for Digoxin. Which of the following findings should the nurse identify as a potential sign of Digoxin toxicity?
- A. Nausea
- B. Dry mouth
- C. Hypoglycemia
- D. Tinnitus
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.