Nokea
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
- A. Prepare an injection of vitamin K
- B. Irrigate the urinary catheter with 50 mL of normal saline
- C. Offer the client additional oral fluids
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
You may also like to solve these questions
The nurse is caring for a client with a history of polycystic ovary syndrome. The nurse should expect the client to have:
- A. Irregular menses
- B. Regular ovulation
- C. Decreased androgen levels
- D. Weight loss
Correct Answer: A
Rationale: Polycystic ovary syndrome disrupts hormonal balance, leading to irregular menses due to anovulation, a hallmark symptom.
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
- A. Must use the least restrictive measure possible to control the behavior
- B. Should put the client in seclusion until he promises to behave appropriately
- C. Should apply full restraints until the behavior is under control
- D. Should allow other clients to observe the acting out so that they can learn from the experience
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
Which complaint is frequently expressed by a client with macular degeneration?
- A. Problems with activities requiring focused vision such as sewing
- B. Severe eye and face pain accompanied by nausea and vomiting
- C. Seeing halos around lights
- D. Veil-like loss of vision
Correct Answer: A
Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.
A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.
The nurse is performing an assessment on a client with a history of pancreatitis. Which finding is most concerning?
- A. Abdominal tenderness
- B. Nausea and vomiting
- C. Fever of 101°F
- D. Grey-Turner’s sign
Correct Answer: D
Rationale: Grey-Turner’s sign (flank bruising) indicates retroperitoneal hemorrhage in pancreatitis, a life-threatening complication requiring immediate attention. Other findings are common but less severe.