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A nurse is caring for a client who has a pulmonary embolism and has been on a heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
- A. Both heparin and warfarin work together to dissolve the clots.
- B. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.
- C. The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay.
- D. I will call the provider to get a prescription for discontinuing the IV heparin today.
Correct Answer: B
Rationale: Overlap therapy is needed because warfarin has delayed onset (3-5 days) while heparin provides immediate anticoagulation.
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The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?
- A. Fractured femur
- B. Severe anorexia nervosa
- C. Gastrointestinal obstruction
- D. Chronic diarrhea and vomiting
Correct Answer: C
Rationale: Gastrointestinal obstruction contraindicates lipid emulsion administration as it could worsen the obstruction.
A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?
- A. The glomerular filtration rate (GFR) recovers.
- B. Urine output is less than 400 mL per 24 hours.
- C. BUN and creatinine levels decrease.
- D. Renal function is reestablished.
Correct Answer: B
Rationale: Oliguria (<400mL/24hr) defines this phase of AKI with impaired urine production.
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A nurse is planning care for a client who has undergone cardiac catheterization through the femoral artery. Which of the following actions should the nurse plan to take?
- A. Instruct the client to perform range-of-motion exercises to his lower extremities.
- B. Ambulate the client 1 hour following the procedure.
- C. Restrict the client's fluid intake.
- D. Assess the color, temperature, and pulse in the affected extremity.
Correct Answer: D
Rationale: Assessing the extremity monitors for vascular complications like bleeding or occlusion post-catheterization.
A nurse is preparing to administer intermittent lipid emulsion and notes a layer of fat floating in the IV solution bag. Which action should the nurse take?
- A. Shake the bag to mix the fat.
- B. Administer the bag of solution.
- C. Return the bag to the pharmacy.
- D. Turn the bag upside down one time.
Correct Answer: C
Rationale: Fat separation indicates instability; solution should be returned to pharmacy as it could cause fat embolism.