Nokea
A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
- A. International normalized ratio (INR) of 1.0.
- B. Prothrombin time (PT) of 12 seconds.
- C. Partial thromboplastin time (PTT) of 60 seconds.
- D. International normalized ratio (INR) of 2.5.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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During a 2 wk postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits bad tenderness, shoulder pain, & describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?
- A. have the client transported via ambulance to the hospital
- B. recheck the client's vital signs in 30 minutes
- C. instruct the client to drive to the hospital for admission
- D. determine the client's current symptoms
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct Answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A public health nurse is planning an educational campaign to reduce the incidence of hypertension in the community. Which group should be the primary target of this campaign?
- A. adolescents
- B. young adults
- C. middle-aged adults
- D. older adults
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An older female client tells the home health nurse that she has no money, and since she does not deserve to eat, she has not asked anyone to bring her food. What information is most important for a nurse to obtain?
- A. client's thoughts about wanting to hurt herself
- B. medication history for antipsychotic agents
- C. availability of family members to provide meals
- D. community resources to provide financial aid
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.