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A nurse is caring for a client who is receiving IV heparin. Which of the following actions should the nurse take?
- A. Monitor the client's prothrombin time (PT).
- B. Administer the heparin via IV push.
- C. Check the client's activated partial thromboplastin time (aPTT).
- D. Instruct the client to increase vitamin K intake.
Correct Answer: C
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation. PT is for warfarin, heparin infuses slowly, and vitamin K counteracts it.
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A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?
- A. Human papillomavirus
- B. Neisseria gonorrhoeae
- C. Impetigo contagious
- D. Sarcoptes scabiei
Correct Answer: B
Rationale: Neisseria gonorrhoeae is a reportable sexually transmitted infection to track and control its spread. HPV, impetigo, and scabies are not typically reportable to state health departments.
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?
- A. Use confrontation to manage the client's behavior.
- B. Limit the number of choices for the client.
- C. Provide a stimulating environment for the client.
- D. Use written signs to assist the client with locating the bathroom.
Correct Answer: B,D
Rationale: Limiting choices reduces confusion, and signs aid navigation. Confrontation increases agitation, and overstimulation can overwhelm clients with Alzheimer's.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I might feel sleepy while taking this medication.
- C. I need to avoid sunlight.
- D. I can increase the dose if my pain gets worse.
Correct Answer: B
Rationale: Tramadol can cause drowsiness, showing understanding. Food isn't required, sunlight isn't a concern, and dose increases need provider approval.
A nurse is caring for a client who is receiving IV fluids. Which of the following findings indicates the client is experiencing fluid overload?
- A. The client's blood pressure is 110/70 mm Hg.
- B. The client's respiratory rate is 24 breaths/min.
- C. The client reports feeling thirsty.
- D. The client's neck veins are distended.
Correct Answer: D
Rationale: Distended neck veins indicate fluid overload, reflecting increased venous pressure. Normal BP, mild tachypnea, or thirst don't specifically signal overload.