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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 client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.
A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct Answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
A client has Clostridium difficile infection. Which of the following actions should the nurse take?
- A. Wash hands with an alcohol-based hand rub.
- B. Place the client on contact precautions.
- C. Wear a mask when entering the client's room.
- D. Double-bag all linens before removing them from the room.
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.
A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?
- A. Tinnitus.
- B. Photosensitivity.
- C. Urinary frequency.
- D. Insomnia.
Correct Answer: B
Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
- A. Substernal retractions
- B. Hematuria
- C. Temperature of 37.9°C (100.2°F)
- D. Sneezing
Correct Answer: A
Rationale: Substernal retractions indicate respiratory distress in a sickle-cell client, which can be a sign of acute chest syndrome. This condition is a serious complication of sickle-cell anemia characterized by chest pain, fever, cough, and shortness of breath. Reporting this symptom promptly is crucial for timely intervention. Choice B, hematuria, is not typically associated with acute chest syndrome but may indicate other issues such as a urinary tract infection. Choice C, a temperature of 37.9°C (100.2°F), is slightly elevated but not a specific indicator of acute chest syndrome. Choice D, sneezing, is not a typical symptom of acute chest syndrome and would not warrant immediate reporting to the provider in this context.