Nokea
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the heparin drip rate
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of vascular assessments
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
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Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A. Place the client in a sitting position.
- B. Administer acetaminophen (Tylenol).
- C. Pinch the soft lower part of the nose.
- D. Apply ice packs to the forehead.
Correct Answer: C
Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.
The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
- A. Acyanosis
- B. Acrocyanosis
- C. Halequin sign
- D. Absent femoral pulses
Correct Answer: D
Rationale: Absent femoral pulses suggest coarctation of the aorta, a critical condition.
The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.