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A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.
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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.
A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?
- A. Thiamine (Vitamin B1)
- B. Cyanocobalamin (Vitamin B12)
- C. Folic acid
- D. Vitamin D
Correct Answer: A
Rationale: The correct answer is A: Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, causing neurological symptoms like confusion and unsteady gait (Wernicke's encephalopathy). Thiamine is crucial for brain function and alcohol interferes with its absorption. Vitamin B12 (choice B) deficiency can also cause neurological symptoms but is less likely in this case. Folic acid (choice C) deficiency can lead to anemia and neural tube defects, not directly related to the symptoms described. Vitamin D (choice D) deficiency typically presents with bone pain and muscle weakness, not confusion and gait issues.
A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which pre-procedure instruction should the nurse provide?
- A. Maintain a low-protein diet for 24 hours before the biopsy.
- B. Avoid taking anticoagulant medications for one week before the biopsy.
- C. Drink plenty of fluids before the procedure.
- D. Take your routine medications with a full glass of water before the biopsy.
Correct Answer: B
Rationale: The correct answer is B: Avoid taking anticoagulant medications for one week before the biopsy. This is essential to prevent excessive bleeding during and after the procedure. Chronic kidney disease patients are at higher risk of bleeding due to impaired kidney function.
A: Maintaining a low-protein diet is not directly related to the biopsy procedure and is not necessary.
C: Drinking plenty of fluids may be beneficial for renal function but is not a specific pre-procedure instruction for a renal biopsy.
D: Taking routine medications with water is important, but specific instructions regarding anticoagulant medications are more critical in this case.
The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?
- A. Hoarseness and a sore throat.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Temperature of 100.2°F (37.9°C).
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent damage to parathyroid glands. Hypocalcemia can lead to tetany, seizures, and cardiac dysrhythmias. Immediate intervention is needed to prevent serious complications.
Hoarseness and a sore throat (A) are expected post-thyroidectomy due to intubation. Difficulty swallowing (B) can be due to swelling but is not immediately life-threatening. A temperature of 100.2°F (37.9°C) (D) is slightly elevated but not a priority in this scenario.
A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?
- A. Walk barefoot whenever possible to toughen your feet.
- B. Soak your feet in hot water daily to improve circulation.
- C. Trim your toenails straight across to prevent ingrown toenails.
- D. Use a heating pad to keep your feet warm.
Correct Answer: C
Rationale: Correct Answer: C - Trim your toenails straight across to prevent ingrown toenails.
Rationale:
1. Trimming toenails straight across helps prevent ingrown nails.
2. Ingrown nails can lead to infection, especially risky for diabetics due to poor wound healing.
3. Walking barefoot toughens feet, increasing risk of injury.
4. Soaking in hot water can cause burns or skin damage.
5. Using a heating pad can lead to burns or decreased sensation in feet, increasing injury risk.
Summary:
Option C is correct as it directly addresses a common issue in diabetic foot care - ingrown toenails. Options A, B, and D pose risks of injury or damage to the feet, which is detrimental for diabetic individuals.