Nokea
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
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Which of the following indicates that the client taking an anticoagulant needs further teaching?
- A. The client states that he will report bruising
- B. The client states that he eats green, leafy vegetables at least three times weekly
- C. The client states that he will return to the doctor's office for scheduled lab work
- D. The client states that his insulin dose might have to be adjusted while he is taking an anticoagulant
Correct Answer: B
Rationale: Green, leafy vegetables are high in vitamin K, which can counteract anticoagulants like warfarin, so consistent intake or dietary counseling is needed.
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
- A. Administer the medication as prescribed.
- B. Administer diphenhydramine before administering cefazolin.
- C. Notify the pharmacy that the medication is not appropriate for the client.
- D. Ask the client for more information about the allergic reaction to amoxicillin.
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.
A low-residue diet is ordered for an adult. The nurse knows that the client understands the diet when which menu is selected?
- A. Lettuce and tomato salad, steak sandwich, orange slices
- B. Gelatin salad, mashed potatoes, sliced chicken
- C. Corn casserole, pork chop, rice
- D. Broccoli, broiled fish, sesame seed roll
Correct Answer: B
Rationale: Gelatin, mashed potatoes, and sliced chicken are low-fiber, low-residue foods, suitable for the diet. Lettuce, corn, broccoli, and sesame seeds are high-fiber, increasing residue.
Which meal should the nurse recommend for a client at 13 weeks gestation?
- A. Baked chicken, turnip greens, peanut butter cookie, and grape juice
- B. Baked swordfish, fries, baked apples, and fat-free milk
- C. Chilled ham and cheese sandwich, broccoli, orange slices, and water
- D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water
Correct Answer: A
Rationale: Baked chicken, greens, cookie, and juice (A) provide balanced nutrients without high-mercury fish (B), deli meats (C), or undercooked liver (D), which pose risks in pregnancy.
Laboratory results
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 30%
(0.30)
Activated PTT
Baseline: 30–40 sec 110 sec
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 80,000/mm3
(80 x 109/L)
PT
11–12.5 sec 11 sec
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Activated PTT(62%)
- B. Hemotocrit(5%)
- C. Platelets(23%)
- D. PT(8%)
Correct Answer: A
Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial
thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40
seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side
effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina
bleeds (Option 1).
(Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic
anemia, a hematocrit of 30% (0.30) may be an expected finding.
(Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver
cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs
with a platelet count >50,000 mm* (50 x 10%/L).
(Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be
concerning.