Nokea
A client with a hip fracture is receiving heparin to prevent thromboembolism. Which laboratory value should the nurse monitor?
- A. Prothrombin time (PT).
- B. Activated partial thromboplastin time (aPTT).
- C. International Normalized Ratio (INR).
- D. Platelet count.
Correct Answer: B
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation.
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A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 3 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
The client is at highest risk for developing ……………..
- A. stroke.
- B. multiple organ dysfunction.
- C. a myocardial infarction.
- D. respiratory acidosis.
Correct Answer: B
Rationale: The client's severe hyperthermia, hypotension, tachycardia, and confusion suggest heat stroke, which can lead to multiple organ dysfunction due to systemic inflammation and hypoperfusion. Stroke (A), myocardial infarction (C), and respiratory acidosis (D) are less directly associated with heat stroke complications.
A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the nurse that he is having trouble hearing. What would be the nurse's best response to this statement?
- A. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to deteriorate.
- B. Have the client immediately report the hearing loss to his physician.
- C. Schedule the client for audiometric testing and a hearing aid.
- D. Tell the client that the hearing loss is only temporary; when his system adjusts to the furosemide, his hearing will improve.
Correct Answer: B
Rationale: Furosemide can cause ototoxicity, leading to hearing loss. The nurse should advise the client to report this to the physician promptly for further evaluation and management.
When using a Doppler instrument to assess peripheral pulses, the correct placement of the transducer is important because it is difficult to differentiate between:
- A. Arterial and capillary blood flow
- B. Arterial and venous blood flow
- C. Arterial and arteriole blood flow
- D. Capillary and venous blood flow
Correct Answer: B
Rationale: Doppler ultrasound can detect both arterial (pulsatile) and venous (continuous) blood flow, but incorrect transducer placement may confuse these signals. Differentiating arterial from venous flow is critical in PVD assessment to confirm arterial patency. Capillary or arteriole flow is less relevant in this context.
The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?
- A. Low-pressure alarm
- B. Increased blood glucose
- C. Diminished lung sounds
- D. Hemoglobinuria
Correct Answer: D
Rationale: Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.