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A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Platelet count
- B. Prothrombin time (PT/INR)
- C. Hemoglobin
- D. Serum potassium
Correct Answer: B
Rationale: Warfarin affects clotting, requiring monitoring of PT/INR to ensure therapeutic anticoagulation. Platelets (A), hemoglobin (C), and potassium (D) are not directly affected.
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The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals to prevent nausea.'
- B. Report a pulse below 60 beats per minute.'
- C. Increase potassium-rich foods in your diet.'
- D. Take an extra dose if you miss one.'
Correct Answer: B
Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg.
- B. Cover the bone area with a sterile dressing.
- C. Apply an ACE bandage around the entire lower limb.
- D. Place the client in the prone position.
Correct Answer: B
Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (A) is secondary, an ACE bandage (C) may contaminate the wound, and prone positioning (D) is inappropriate.
A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?
- A. Mild fatigue
- B. Hypotension
- C. Slight headache
- D. Stable weight
Correct Answer: B
Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (A), headache (C), and stable weight (D) are less concerning.
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:
- A. Glucocorticoid followed by the bronchodilator
- B. Bronchodilator followed by the glucocorticoid
- C. Alternate successive administrations
- D. According to the client's preference
Correct Answer: B
Rationale: The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. Client teaching regarding the use and effects of inhalers will promote client understanding and compliance.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.