Nokea
A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the LPN/LVN expect to assist with first?
- A. Administer a diuretic as prescribed.
- B. Place the client in a high Fowler's position.
- C. Prepare the client for intubation.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: In a client with pulmonary edema, placing them in a high Fowler's position is the priority intervention. This position helps to improve ventilation and oxygenation by decreasing venous return, reducing the workload on the heart, and facilitating fluid redistribution from the lungs. It is crucial to optimize respiratory function and oxygenation before considering other interventions like administering medications, preparing for intubation, or inserting a urinary catheter.
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A client with atrial fibrillation is receiving warfarin (Coumadin). The nurse should monitor which laboratory test to determine the effectiveness of the therapy?
- A. Prothrombin time (PT) and international normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Complete blood count (CBC)
- D. Fibrinogen level
Correct Answer: A
Rationale: To monitor the effectiveness of warfarin therapy in a client with atrial fibrillation, the nurse should assess the Prothrombin time (PT) and international normalized ratio (INR) levels. These tests help determine the clotting ability of the blood and ensure that the client's anticoagulation levels are within the therapeutic range, reducing the risk of bleeding or clotting complications.
The healthcare professional is assisting in the care of a client diagnosed with deep vein thrombosis (DVT). Which instruction should be reinforced to prevent complications?
- A. Elevate the affected leg using pillows.
- B. Perform leg exercises while sitting.
- C. Wear snug compression stockings.
- D. Avoid applying ice packs to injuries.
Correct Answer: A
Rationale: Elevating the affected leg using pillows is essential in managing deep vein thrombosis (DVT) as it helps reduce swelling and promote venous return, thus decreasing the risk of complications such as pulmonary embolism. This position aids in improving blood circulation and preventing blood clots from forming or worsening in the affected leg.
The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?
- A. Obtain a 12-lead ECG
- B. Monitor the client's blood pressure
- C. Notify the healthcare provider
- D. Administer a second dose of nitroglycerin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is teaching a client about the use of nitroglycerin patches for angina pectoris. Which instruction should the healthcare provider include?
- A. Apply the patch to the same site each day
- B. Remove the patch at bedtime to prevent tolerance
- C. Cover the patch with a bandage to keep it in place
- D. Rotate the application site every 24 hours
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is receiving anticoagulant therapy for atrial fibrillation. Which laboratory test should be monitored to determine the effectiveness of the therapy?
- A. Prothrombin time (PT) and international normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are essential laboratory tests to monitor the effectiveness of anticoagulant therapy in clients with atrial fibrillation. These tests help ensure that the client is within the therapeutic range and are commonly used to assess the clotting ability of the blood. Monitoring PT and INR levels allows healthcare providers to adjust anticoagulant dosages as needed to prevent complications such as bleeding or thrombosis.