Nokea
A nurse is caring for a patient who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse monitor? Which lab test should the nurse monitor for heparin?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). aPTT is the most appropriate lab test to monitor for patients receiving heparin therapy because it reflects the drug's anticoagulant effect. Heparin works by inhibiting thrombin and factor Xa, which can be measured effectively by monitoring aPTT levels. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for potential heparin-induced thrombocytopenia, but aPTT is more directly related to heparin's anticoagulant effect.
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A nurse is caring for a patient whose right leg is in Buck's traction. Which interventions should the nurse implement to promote the patient's mobility? Which intervention promotes mobility in Buck's traction?
- A. Perform passive range of motion exercises on the right leg.
- B. Perform isometric exercises on both legs.
- C. Perform active range-of-motion exercises on the left leg.
- D. Log roll the patient every 2 hours.
Correct Answer: C
Rationale: Rationale: Performing active range-of-motion exercises on the left leg promotes mobility in Buck's traction by maintaining muscle strength and joint flexibility, preventing muscle atrophy, and improving circulation. This helps prevent complications and supports eventual rehabilitation. Passive range of motion exercises on the right leg are not recommended as it may cause discomfort. Isometric exercises on both legs may not address the specific immobilization of the right leg. Log rolling every 2 hours is not directly related to promoting mobility in Buck's traction.
A nurse is instructing a patient who has just been prescribed bumetanide. What should the nurse include in the instructions? What should the nurse include in bumetanide instructions?
- A. Take the prescribed second dose at nighttime.
- B. Limit your fluid intake to no more than 1.5 L a day.
- C. Report any changes in hearing.
- D. Avoid foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Report any changes in hearing. Bumetanide is a loop diuretic that can cause ototoxicity, leading to changes in hearing. Instructing the patient to report any changes in hearing is crucial to monitor for potential adverse effects. Choice A is incorrect as bumetanide is usually taken once daily in the morning to prevent nocturia. Choice B is incorrect as the patient may need to increase fluid intake to prevent dehydration. Choice D is incorrect as bumetanide can lead to hypokalemia, so foods high in potassium may be beneficial.
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following patients should the nurse identify as requiring airborne precautions? Which patient requires airborne precautions?
- A. A patient who has streptococcal pharyngitis
- B. A patient who has scabies
- C. A patient who has measles
- D. A patient who has pertussis
Correct Answer: C
Rationale: The correct answer is C: A patient who has measles. Measles is a highly contagious airborne disease spread through respiratory droplets. Airborne precautions are necessary to prevent transmission. Streptococcal pharyngitis (A) is spread through direct contact or respiratory droplets, not airborne. Scabies (B) is transmitted through skin-to-skin contact, not airborne. Pertussis (D) is spread through respiratory droplets, but not as easily as measles, so airborne precautions are not typically required.
A nurse is caring for a patient who has a new prescription for sertraline. Which of the following instructions should the nurse include? What instructions should the nurse include for sertraline?
- A. Take the medication at bedtime.
- B. Take the medication with food.
- C. Avoid driving for the first week.
- D. Report any weight loss.
Correct Answer: A
Rationale: The correct answer is A: Take the medication at bedtime. Sertraline is an antidepressant that is commonly prescribed to be taken in the evening or at bedtime because it can cause drowsiness. This timing helps minimize potential side effects such as dizziness or drowsiness during waking hours. Taking it at bedtime also helps with patient compliance. Choice B is incorrect because sertraline can be taken with or without food. Choice C is incorrect as there is no specific need to avoid driving only for the first week. Choice D is incorrect because weight loss is not a common side effect of sertraline and does not need to be reported.
History & Physical (0700hrs)
Date: 06/28/0X
• Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
• Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
• Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
• Endometriosis diagnosed.
Provider's Prescriptions (0700hrs)
• Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
Nurse's Notes (0700hrs)
• Client reports adherence to nafarelin regimen without missing doses.
• Client verbalizes irritation in the nasal mucosa.
• Reports feeling better overall with decreased dyspareunia.
• Notes decreased pain during bowel movements.
• Reports decreased pelvic pain and the absence of menstruation last month.
• Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
• Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic
Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.)
- A. CNS manifestations
- B. Pain level during sexual intercourse
- C. Nasal mucosa changes
- D. Breast changes
- E. Missed previous month's menstrual cycle
- F. Dermatological manifestations
Correct Answer: B,E
Rationale: The correct answers are B and E. Nafarelin is a gonadotropin-releasing hormone (GnRH) agonist used to treat endometriosis by suppressing estrogen production, thereby reducing symptoms like pain during intercourse (choice B) and causing missed menstrual cycles (choice E). These are therapeutic effects. Choices A, C, D, and F are incorrect because CNS manifestations, nasal mucosa changes, breast changes, and dermatological manifestations are not commonly reported therapeutic effects of nafarelin. Thus, options A, C, D, and F can be ruled out.