Nokea
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
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A client is experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?
- A. Albuterol (Proventil)
- B. Ipratropium (Atrovent)
- C. Salmeterol (Serevent)
- D. Fluticasone (Flovent)
Correct Answer: A
Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms.
Summary of other choices:
B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief.
C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations.
D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations
What educational information related to nutrition would you provide to a client with anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
- A. The client demonstrates a good understanding of stoma care.
- B. The client has joined a book club that meets at the library.
- C. Family members take turns assisting with stoma care.
- D. Skin around the stoma is intact without signs of infection.
Correct Answer: B
Rationale: The correct answer is B because joining a book club indicates the client is engaging in social activities and pursuing interests, which can boost self-esteem. Choice A focuses on physical care, not self-esteem. Choice C involves family support, not necessarily self-esteem. Choice D only addresses physical health, not emotional well-being. Overall, engaging in social activities promotes self-worth and a sense of belonging, aligning with the goal of improving self-esteem.
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.
In planning Mr. Jones’ discharge teaching, what is important to emphasize?
- A. He should not leave his home without wearing a mask
- B. Medications must be taken as ordered
- C. All visitors to his home should wear masks
- D. He is cured of tuberculosis
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.