Nokea
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory test should the nurse monitor to determine the effectiveness of the medication?
- A. Platelet count.
- B. Prothrombin time (PT) and international normalized ratio (INR).
- C. Activated partial thromboplastin time (aPTT).
- D. Fibrinogen level.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and international normalized ratio (INR). Warfarin works by inhibiting vitamin K-dependent clotting factors, affecting the PT and INR. Monitoring these levels helps assess the effectiveness of warfarin in preventing clot formation. Platelet count (A) assesses clotting ability but not the effectiveness of warfarin. Activated partial thromboplastin time (C) assesses intrinsic pathway clotting factors, not affected by warfarin. Fibrinogen level (D) assesses the final step of clot formation, not specific to warfarin effectiveness.
You may also like to solve these questions
A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
- A. Check the client's blood glucose level.
- B. Administer 10 units of insulin.
- C. Give the client a high-protein snack.
- D. Measure the client's blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Check the client's blood glucose level. The client's symptoms are indicative of hypoglycemia, which is a common complication in diabetes mellitus. Checking the blood glucose level will confirm the diagnosis and guide appropriate interventions. Administering insulin (B) could worsen the hypoglycemia. Giving a high-protein snack (C) may help raise blood sugar levels but should be done after confirming the diagnosis. Measuring blood pressure (D) is not the priority in this situation.
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct Answer: B
Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence.
Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being.
Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship.
Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed.
Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.
A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
- A. Decreased libido is a common side effect of SSRIs and may improve over time.
- B. I will notify your healthcare provider to discuss possible medication changes.
- C. You should take your medication with food to reduce side effects.
- D. Increase your daily exercise to help manage this side effect.
Correct Answer: B
Rationale: The correct response is B: I will notify your healthcare provider to discuss possible medication changes. This is the best choice because decreased libido is a common side effect of SSRIs that can significantly impact the client's quality of life. Consulting the healthcare provider is crucial to explore alternative treatment options or adjustments to improve the client's symptoms. Choices A, C, and D do not address the underlying issue of decreased libido and are unlikely to provide effective solutions. Choice A only acknowledges the side effect without offering a proactive solution. Choice C is unrelated to the sexual side effect and may not address the client's concerns. Choice D suggests a general lifestyle change that may not directly address the medication side effect. Consulting the healthcare provider for medication adjustments is the most appropriate action to address this specific side effect.
A client with Addison's disease is being treated with fludrocortisone (Florinef). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hypernatremia. Fludrocortisone is a mineralocorticoid that promotes sodium retention and potassium excretion, leading to an increase in sodium levels. Addison's disease involves low levels of cortisol and aldosterone, so fludrocortisone is used to replace aldosterone. Monitoring for hypernatremia is crucial to prevent complications like hypertension and fluid retention. Hyperkalemia (A) is not expected due to the drug's potassium-excreting effect. Hyponatremia (B) is unlikely as the drug promotes sodium retention. Hypocalcemia (D) is not directly related to fludrocortisone therapy.
The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Serosanguineous drainage in the collection chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Chest tube secured to the client's chest wall.
Correct Answer: A
Rationale: The correct answer is A: Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber indicates an air leak in the system, which can lead to pneumothorax or compromised lung function. Immediate intervention is required to prevent complications. Serosanguineous drainage in the collection chamber (B) is expected after thoracotomy. Intermittent bubbling in the suction control chamber (C) is normal and indicates proper suction function. Chest tube secured to the client's chest wall (D) is essential for stability and should not require immediate intervention.