Nokea
A nurse Is evaluating the laboratory results of four clents. The nurse should report which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- C. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
- D. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A client with a prescription for heparin and an aPTT of 90 seconds indicates that the client's blood is taking too long to clot, which puts the client at risk for bleeding. The aPTT range for a client on heparin therapy is 30-40 seconds, so a result of 90 seconds is significantly elevated and requires immediate attention to prevent bleeding complications.
Summary of other choices:
B: A client with a prescription for heparin and an aPTT of 65 seconds falls within the normal range of 30-40 seconds, so this result does not require immediate reporting.
C: A client with a prescription for warfarin and an INR of 3.0 is within the therapeutic range (2-3) for warfarin therapy, so this result does not require immediate reporting.
D: A client with a prescription for warfarin and an INR of 2.0 is also
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A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
- A. Nausea
- B. Cardiac dysrhythmia
- C. Laryngeal edema
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Laryngeal edema. Laryngeal edema is a severe allergic reaction symptom that can lead to airway obstruction and respiratory distress. This is a life-threatening condition that requires immediate intervention. Nausea (A) and insomnia (D) are common side effects of amoxicillin but not indicative of an allergic reaction. Cardiac dysrhythmia (B) is not a typical allergic reaction symptom to amoxicillin.
A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?
- A. Withdraw the regular insulin from the vial
- B. Withdraw the NPH insulin from the vial
- C. Inject air into the NPH vial
- D. Inject air into the regular insulin vial
Correct Answer: C
Rationale: The correct answer is C: Inject air into the NPH vial. This step is crucial to prevent creating a vacuum in the vial when withdrawing the NPH insulin, ensuring accurate dosage measurement. Injecting air into the NPH vial equalizes pressure, making it easier to withdraw the correct amount of insulin without causing air bubbles.
Choice A is incorrect as withdrawing regular insulin first may lead to air being drawn into the syringe when withdrawing NPH insulin. Choice B is incorrect because withdrawing NPH insulin first without equalizing pressure may cause difficulty in drawing the correct amount of insulin. Choice D is incorrect as injecting air into the regular insulin vial before withdrawing NPH insulin is unnecessary and may introduce air bubbles into the syringe.
A nurse is caring for a client who is taking digoxin to treat heart failure. Which of the following predisposes this client to developing digoxin toxicity?
- A. Taking a high ceiling diuretic
- B. Having a 10-year history of COPD
- C. Having a prolapsed mitral valve
- D. Taking an HMG CoA reductase inhibitor
Correct Answer: A
Rationale: The correct answer is A: Taking a high ceiling diuretic. High ceiling diuretics, such as furosemide, can lead to hypokalemia, which increases the risk of digoxin toxicity. Digoxin competes with potassium for binding sites on the Na+/K+-ATPase pump in the heart, so low potassium levels can lead to an increased concentration of digoxin in the body, predisposing the client to toxicity. Choices B, C, and D are incorrect as they do not directly impact digoxin levels or toxicity. A history of COPD (B) or a prolapsed mitral valve (C) do not specifically predispose a client to digoxin toxicity. Taking an HMG CoA reductase inhibitor (D) does not interact directly with digoxin.
A nurse is administering 4 mg of hydromorphone to a client by mouth every 4 hr. The medication is provided as hydromorphone 8 mg per tablet. Which of the following actions is appropriate for the nurse to take?
- A. Return the remaining medication to the facility's pharmacy.
- B. Store the remaining half of the pill in the automated medication dispensing system.
- C. Place the remaining half of the pill in the unit dose package.
- D. Dispose of the remaining medication while another nurse observes.
Correct Answer: D
Rationale: The correct answer is D: Dispose of the remaining medication while another nurse observes. This is the appropriate action because hydromorphone is a controlled substance with high abuse potential. The nurse should follow proper medication disposal protocols to prevent diversion or misuse. Returning the medication to the pharmacy (choice A) may not ensure proper disposal. Storing the remaining half of the pill in the automated medication dispensing system (choice B) or placing it in the unit dose package (choice C) could lead to unauthorized access. Disposing of the medication while another nurse observes (choice D) ensures accountability and adherence to safety measures.
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.