Nokea
A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?
- A. Monitor the client's blood pressure continuously
- B. Weigh the client daily
- C. Monitor the infusion site for signs of infiltration
- D. Measure the client's intake and output every 2 hours
Correct Answer: D
Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.
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A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?
- A. aPTT 75 seconds.
- B. INR 1.2.
- C. Hemoglobin 10 g/dL.
- D. Fibrinogen level 350 mg/dL.
Correct Answer: A
Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.
A nurse is preparing to administer packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Prime the IV tubing with dextrose 5% in water
- B. Ensure the client's consent is on file
- C. Check the client's identification using two identifiers
- D. Administer the blood through a 22-gauge catheter
Correct Answer: C
Rationale: The correct first action for the nurse to take when preparing to administer packed RBCs is to check the client's identification using two identifiers. This step is crucial to ensure that the right blood is given to the right client, preventing any transfusion errors. Priming the IV tubing with dextrose 5% in water and administering the blood through a 22-gauge catheter are important steps but should come after confirming the client's identity. Ensuring the client's consent is on file is also important but is not the immediate priority when preparing to administer packed RBCs.
A client has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Hemoglobin
Correct Answer: A
Rationale: When a client is prescribed furosemide, monitoring potassium levels is crucial due to the drug's potential to cause hypokalemia. Furosemide is a loop diuretic that promotes potassium excretion in the urine, leading to a risk of low potassium levels. Monitoring potassium levels helps in detecting and preventing hypokalemia, which can result in adverse effects like cardiac dysrhythmias. Sodium, calcium, and hemoglobin levels are usually not directly affected by furosemide, making them less pertinent for monitoring in this specific scenario.
A client practicing Orthodox Judaism informs the nurse they are observing the Passover holiday. Which action should the nurse include in the plan of care?
- A. Provide chicken with cream sauce
- B. Avoid serving fish with fins and scales
- C. Provide unleavened bread
- D. Avoid serving foods containing lamb
Correct Answer: C
Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include consuming unleavened bread. This symbolizes the haste with which the Israelites left Egypt and the lack of time for bread to rise. Providing chicken with cream sauce (Choice A) is not aligned with Passover dietary restrictions. Avoiding serving fish with fins and scales (Choice B) is a general dietary law in Judaism but not specific to Passover. Similarly, avoiding foods containing lamb (Choice D) is not a specific requirement during Passover.
A client reports intimate partner violence to a nurse. What is the nurse's priority action?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Ensure the client has access to legal services.
Correct Answer: A
Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.