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A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.
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A nurse is caring for a client who is postoperative following a knee arthroscopy. Which of the following actions should the nurse take?
- A. Apply a warm compress to the surgical site.
- B. Elevate the client's leg.
- C. Encourage the client to bear weight immediately.
- D. Administer a stool softener daily.
Correct Answer: B
Rationale: Elevating the leg reduces swelling and promotes recovery. Warm compresses risk inflammation, early weight-bearing may harm, and stool softeners aren't routine.
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 a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?
- A. You might experience weight loss while taking this medication.
- B. You should expect to have increased energy within a few days.
- C. You might feel drowsy, so avoid driving until you know how this medication affects you.
- D. You can stop taking this medication as soon as your symptoms improve.
Correct Answer: C
Rationale: Amitriptyline can cause drowsiness, so avoiding driving is prudent. Weight gain, not loss, is common, effects take weeks, and abrupt stopping risks relapse.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication on an empty stomach.
- B. I might need to take this medication for several weeks.
- C. I can stop taking this medication if I feel better.
- D. I should avoid getting vaccinated while taking this medication.
Correct Answer: B
Rationale: Prednisone often requires weeks of treatment for efficacy, reflecting understanding. It's taken with food, stopping abruptly risks adrenal crisis, and vaccines need provider guidance.