Nokea
A client receiving warfarin (Coumadin) therapy should have which of the following laboratory results reviewed to evaluate the effectiveness of the therapy?
- A. Complete blood count (CBC).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Partial thromboplastin time (PTT).
Correct Answer: C
Rationale: The correct answer is C: International normalized ratio (INR). The INR is the most appropriate laboratory result to review when evaluating the effectiveness of warfarin (Coumadin) therapy. Warfarin is an anticoagulant medication, and the INR helps determine if the dosage is within a therapeutic range to prevent clotting or bleeding complications. Choice A, a Complete Blood Count (CBC), provides information about the cellular components of blood but does not directly assess the anticoagulant effects of warfarin. Choice B, Prothrombin time (PT), measures the time it takes for blood to clot but is not as specific for monitoring warfarin therapy as the INR. Choice D, Partial Thromboplastin Time (PTT), evaluates the intrinsic pathway of coagulation and is not the primary test used to monitor warfarin therapy.
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The healthcare provider provides dietary instructions about iron-rich food to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver
- B. Kidney beans
- C. Oranges
- D. Leafy green vegetables
Correct Answer: C
Rationale: Oranges are not a good source of iron, so selecting oranges indicates a need for additional instructions. Oranges are high in vitamin C, which can enhance iron absorption from other sources, but they are not rich in iron themselves. Liver, kidney beans, and leafy green vegetables are good sources of iron and would be beneficial for a client with iron deficiency anemia. Therefore, the correct answer is C.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: Alteplase recombinant, or t-PA, is a thrombolytic enzyme used to dissolve clots and revascularize the blocked coronary artery in patients experiencing a myocardial infarction (MI). Administering t-PA within the first 6 hours of MI onset is crucial to restore blood flow to the affected area and minimize cardiac tissue damage. Therefore, the correct answer is to revascularize the blocked coronary artery. Choices A, B, and C are incorrect because while controlling chest pain, reducing coronary artery vasospasm, and managing arrhythmias are important goals in managing MI, the primary purpose of administering t-PA within the first 6 hours is to restore blood flow by dissolving clots and revascularizing the blocked coronary artery.
How can a nurse best help a client undergoing a bone marrow aspiration and biopsy, along with two upset family members, manage anxiety during the procedure?
- A. Allow the client's family to stay for emotional support.
- B. Accompany the client silently.
- C. Encourage the client to take slow, deep breaths to promote relaxation.
- D. Provide the client an opportunity to verbalize emotions.
Correct Answer: C
Rationale: Encouraging the client to take slow, deep breaths is an effective way for the nurse to help the client manage anxiety during the bone marrow aspiration and biopsy procedure. Slow, deep breathing can promote relaxation and help reduce anxiety levels. Choice A, allowing the client's family to stay for emotional support, may provide comfort but does not address a direct intervention to help manage anxiety. Choice B, staying with the client silently, may not actively help the client address their anxiety. Choice D, allowing the client to express feelings, is important but may not directly address anxiety management during the procedure.
A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120g/L) and the hematocrit is 35% (0.35). Which action should the nurse prepare to take?
- A. Continue monitoring for blood loss
- B. Administer 1,000 mL (1L) of normal saline
- C. Transfuse 2 units of platelets
- D. Prepare the client for emergency surgery
Correct Answer: D
Rationale: The correct answer is to prepare the client for emergency surgery. The client's presentation with bright red blood in vomitus suggests active bleeding, which is a medical emergency. With a hemoglobin of 12 g/dL and a hematocrit of 35%, the client is likely experiencing significant blood loss that may require surgical intervention to address the source of bleeding. Continuing to monitor for blood loss (Choice A) is not appropriate in this acute situation where immediate action is necessary. Administering normal saline (Choice B) may help with fluid resuscitation but does not address the underlying cause of bleeding. Transfusing platelets (Choice C) is not indicated in this scenario as platelets are involved in clot formation and are not the primary treatment for active bleeding in this context.
The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Increased blood pressure.
- C. Cloudy dialysate outflow.
- D. Decreased urine output.
Correct Answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.