Nokea
A client is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse should prepare the client by reinforcing information about which post-operative care measure?
- A. You will be on bed rest for the first 48 hours after surgery.
- B. You will be encouraged to cough and deep breathe frequently.
- C. You will be discharged within 24 hours if no complications arise.
- D. You will not be able to eat or drink for 24 hours after surgery.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?
- A. Administer morphine
- B. Obtain an electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Administer sublingual nitroglycerin
Correct Answer: B
Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action.
A client is receiving intravenous heparin therapy for the treatment of deep vein thrombosis (DVT). Which laboratory test result should the LPN/LVN monitor to ensure the client is receiving a therapeutic dose?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct laboratory test result that the LPN/LVN should monitor to ensure the client is receiving a therapeutic dose of heparin therapy is the activated partial thromboplastin time (aPTT). The aPTT test is specifically used to monitor heparin therapy, ensuring that the dose administered is within the therapeutic range. Monitoring aPTT helps to prevent complications such as bleeding or clot formation by maintaining the appropriate anticoagulant effect of heparin.
The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?
- A. Blood glucose
- B. Serum sodium
- C. Serum potassium
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?
- A. Avoid consuming foods high in vitamin K while taking this medication.
- B. Administer the injection in the same site each time for consistency.
- C. Report any unusual bleeding or bruising to your healthcare provider.
- D. Do not take aspirin if you experience any mild pain or discomfort.
Correct Answer: C
Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is important because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin, and should be promptly addressed by a healthcare provider to prevent complications.
The client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?
- A. Hypertension
- B. Bradycardia
- C. Hyperglycemia
- D. Insomnia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.