Nokea
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. Red blood cell count: 5.8 million/µL
- D. White blood cell count: 8.7/µL
Correct Answer: B
Rationale: A platelet count of 82,000/µL is low and may indicate heparin-induced thrombocytopenia (HIT), a serious side effect of heparin therapy. The other laboratory values are within normal ranges and do not suggest a serious adverse effect.
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A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
- A. The client is able to initiate spontaneous breaths
- B. The inspired oxygen has adequate humidification
- C. The upper peak airway pressure limit alarm is off
- D. The upper peak airway pressure limit alarm is on
Correct Answer: D
Rationale: The upper peak airway pressure limit alarm must be on to prevent lung injury from excessive pressure. This is the priority to ensure client safety.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
- A. Chest wall stiffness
- B. Decreased muscle strength
- C. Inability to cooperate
- D. Less lung elasticity
- E. Poor vision and hearing
Correct Answer: A,B,D
Rationale: Age-related changes like chest wall stiffness, decreased muscle strength, and reduced lung elasticity impair weaning from mechanical ventilation. Inability to cooperate and sensory deficits are not universal in older adults.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse is best?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Obtain a STAT chest X-ray
- C. Prepare to administer thrombolytic therapy
- D. Monitor the client's blood pressure every 15 minutes
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
- A. Assess for other manifestations of hypoxia
- B. Change the sensor on the pulse oximeter
- C. Obtain a new oximeter from central supply
- D. Tell the client to take slow, deep breaths
Correct Answer: A
Rationale: Pulse oximetry can sometimes produce normal readings despite hypoxia due to factors like poor peripheral perfusion. A thorough assessment for other signs of hypoxia (e.g., tachycardia, confusion) is the most appropriate action to confirm the client's status.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
- A. Allow visitors at the client's bedside
- B. Ensure the client can communicate if awake
- C. Keep the television tuned to a favorite channel
- D. Provide back and hand massages when turning
- E. Turn the client every 2 hours or more
Correct Answer: A,B,D,E
Rationale: Comfort measures for ventilated clients include allowing visitors, enabling communication (e.g., via writing boards), providing massages during turning, and frequent repositioning to prevent pressure injuries. Keeping the TV on may disrupt rest.