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A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
- A. Increase the infusion rate.
- B. Administer protamine sulfate immediately.
- C. Stop the heparin infusion for 1 hr.
- D. Decrease the heparin dose.
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
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A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first?
- A. Administer oxygen using a high-concentration mask.
- B. Give the client cold fluids orally.
- C. Apply a heating pad to prevent shivering.
- D. Encourage the client to walk to promote circulation.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen using a high-concentration mask. In exertional heat stroke, the body's ability to regulate temperature is compromised, leading to confusion, high temperature, and low blood pressure. Oxygen therapy helps support oxygenation during heat stress. It takes priority to ensure adequate oxygenation and prevent hypoxia, which can worsen the client's condition. Choices B, C, and D are incorrect. Giving cold fluids orally can potentially induce shock in a hypotensive client. Applying a heating pad can lead to further increase in body temperature. Encouraging the client to walk can exacerbate heat stress and increase the risk of collapse.
A nurse is assessing a client who has Cushings syndrome. Which of the following findings should the nurse expect?
- A. Osteoporosis
- B. Hypertension
- C. Weight loss
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. In Cushing's syndrome, excess cortisol weakens bones, leading to osteoporosis. B: Hypertension is common in Cushing's due to cortisol's effects on blood vessels. C: Weight gain, not loss, is typically seen in Cushing's due to cortisol-induced fat redistribution. D: Hyperglycemia, not hypoglycemia, is common due to cortisol's role in glucose metabolism. E, F, G are irrelevant. In summary, osteoporosis is expected due to cortisol's impact on bone health, while the other options are not typical findings in Cushing's syndrome.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, the lungs are unable to eliminate enough carbon dioxide, leading to an increase in CO2 levels in the blood, causing acidosis. This is due to inadequate ventilation or impaired gas exchange. The other options are incorrect because: B) Loss of bicarbonate is seen in metabolic acidosis, not respiratory acidosis. C) Excessive vomiting leads to metabolic alkalosis, not respiratory acidosis. D) Hyperventilation would actually correct respiratory acidosis by decreasing CO2 levels.
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.