Nokea
A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?
- A. Auscultate breath sounds.
- B. Measure vital signs.
- C. Palpate the abdomen.
- D. Observe the skin for bruising.
Correct Answer: C
Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.
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A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?
- A. Monitor the site for further complications.
- B. Promptly remove the catheter from the radial artery.
- C. Elevate the client's arm above the heart.
- D. Notify the healthcare provider and prepare for surgery.
Correct Answer: B
Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.
A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?
- A. Platelet count
- B. Prothrombin time (PT)
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: B
Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.
A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?
- A. Prothrombin time (PT)
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
Correct Answer: C
Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?
- A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
- B. A client with a myocardial infarction that is free from pain and dysrhythmias
- C. A client with a tracheotomy of 24 hours in some respiratory distress
- D. A client with a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.
A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?
- A. Monitor the client's liver function tests.
- B. Monitor the client's prothrombin time (PT).
- C. Monitor the client's partial thromboplastin time (PTT).
- D. Monitor the client's red blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.