Nokea
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?
- A. Hemoglobin
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: aPTT. The activated partial thromboplastin time (aPTT) is monitored to assess the therapeutic effect of heparin and to adjust the infusion rate if needed. Monitoring hemoglobin levels (choice A) is important for assessing anemia but is not specific to heparin therapy. INR (choice C) is used to monitor the effects of warfarin, not heparin. Platelet count (choice D) is important to monitor for heparin-induced thrombocytopenia, but aPTT is the primary laboratory value used to monitor heparin therapy.
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A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Administer ibuprofen 400 mg PO
- B. Administer oxycodone 10 mg PO
- C. Reposition the client to the unaffected side
- D. Apply a cold compress to the affected knee
Correct Answer: B
Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.
A nurse is providing education to a client who is at 28 weeks gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make?
- A. You will need to increase your protein intake during pregnancy.
- B. It is important to monitor your blood glucose levels closely.
- C. Gestational diabetes can increase the risk of developing type 2 diabetes later in life.
- D. You will need to avoid exercise while managing your blood sugar.
Correct Answer: C
Rationale: The correct statement the nurse should make is that gestational diabetes can increase the risk of developing type 2 diabetes later in life. This information is crucial for the client's understanding of the potential long-term implications of gestational diabetes. Monitoring blood glucose levels closely (Choice B) is also important but does not address the long-term risk of developing type 2 diabetes. Choices A and D are incorrect as increasing protein intake during pregnancy and avoiding exercise are not recommended strategies for managing gestational diabetes.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation.
- B. Osteoarthritis.
- C. Hypertension.
- D. Primary glaucoma.
Correct Answer: C
Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.
A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. "You can take this medication with a full glass of water."
- B. "You should store this medication in the refrigerator."
- C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
- D. "You should avoid eating foods high in sodium while taking this medication."
Correct Answer: C
Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.