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A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
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A nurse is preparing to administer a dose of digoxin to a client who has heart failure. Which of the following actions should the nurse take prior to administering the medication?
- A. Monitor the client's respiratory rate.
- B. Assess the client's apical pulse.
- C. Review the client's potassium level.
- D. Monitor the client's fluid intake.
Correct Answer: B
Rationale: The correct action the nurse should take prior to administering digoxin is to assess the client's apical pulse. Digoxin is known to affect the heart rate, potentially causing bradycardia. Monitoring the client's respiratory rate (Choice A) is not directly related to administering digoxin. Reviewing the client's potassium level (Choice C) is important but not a direct prerequisite for administering digoxin. Monitoring the client's fluid intake (Choice D) is also important but not a specific action to take just before administering digoxin.
A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?
- A. There is no fluctuation in the water seal chamber.
- B. There is continuous bubbling in the suction control chamber.
- C. There is tidaling in the water seal chamber.
- D. The drainage system is positioned at the level of the client's chest.
Correct Answer: A
Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.
A client with schizophrenia is pacing the hall and is agitated. Which of the following actions should the nurse take?
- A. Ask the client if they intend to harm others.
- B. Tell the client to stop pacing the hall.
- C. Allow the client to pace alone until they feel less anxious.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with schizophrenia who is pacing the hall and agitated is to walk with the client at a gradually slower pace. This approach can help reduce the client's agitation and prevent the situation from escalating. Choice A is incorrect because directly asking about harm may increase the client's anxiety. Choice B is inappropriate as it may worsen the client's agitation. Choice C is not recommended as the client may benefit from the nurse's presence and support during this time of distress.
A client in active labor is being assessed by a nurse. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. FHR baseline of 170/min.
- C. Early decelerations in the FHR.
- D. Temperature of 37.4°C (99.3°F).
Correct Answer: B
Rationale: The correct answer is B because a baseline FHR of 170/min indicates fetal tachycardia, which needs further evaluation. Choice A about contractions lasting 80 seconds is within the normal range for active labor. Choice C, early decelerations in the FHR, are generally considered benign and do not require immediate reporting. Choice D, a temperature of 37.4°C (99.3°F), falls within normal limits for a laboring client and does not warrant immediate reporting.
A client who is at 10 weeks of gestation and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include?
- A. You should eat crackers before getting out of bed.
- B. You should drink ginger ale with your meals.
- C. You should lie down for 30 minutes after eating.
- D. You should avoid eating between meals.
Correct Answer: A
Rationale: The correct answer is A: 'You should eat crackers before getting out of bed.' Eating crackers before getting out of bed can help reduce nausea and vomiting during pregnancy. This recommendation helps in stabilizing blood sugar levels before fully waking up. Choice B is incorrect because ginger ale may exacerbate nausea due to its carbonation. Choice C is incorrect as lying down after eating can worsen symptoms of nausea. Choice D is incorrect as avoiding eating between meals can lead to low blood sugar levels, worsening nausea and vomiting.