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A nurse is monitoring the laboratory values of a client who is receiving heparin. Which of the following values should the nurse report to the provider?
- A. PT 11 seconds
- B. APTT 50 seconds
- C. Hematocrit 456%
- D. Platelets 300,000/mm²
Correct Answer: C
Rationale: The correct answer is C: Hematocrit 456%. An elevated hematocrit could indicate dehydration or hemoconcentration, which may increase the risk of clotting in a client receiving heparin, a blood thinner. The nurse should report this value to the provider for further evaluation and possible adjustment of the heparin dosage. The other choices are incorrect because: A) PT of 11 seconds is within the normal range; B) APTT of 50 seconds is within the therapeutic range for heparin therapy; D) Platelet count of 300,000/mm² is within normal limits.
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A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client. The client tells the nurse, 'I no longer want to receive this vaccine.' Which of the following responses should the nurse make?
- A. If I were you, I would get the vaccine to keep my family safe.
- B. Influenza can be very serious to anyone who does not receive the vaccine.
- C. The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form.
- D. The influenza vaccine is strongly encouraged, but I understand you would like to decline right now.
Correct Answer: D
Rationale: The correct response is option D. The nurse acknowledges the client's decision to decline the vaccine while also expressing understanding and respect for their choice. This approach maintains the client's autonomy and promotes a therapeutic nurse-client relationship. Option A is incorrect as it disregards the client's autonomy and attempts to influence their decision based on personal opinion. Option B uses fear tactics and does not respect the client's decision-making capacity. Option C is incorrect as it is coercive and goes against the client's right to refuse treatment. It is important for the nurse to provide education and support while respecting the client's decision, making option D the most appropriate response.
A nurse is preparing to titrate a continuous nitroprusside infusion for a client. The nurse should plan to titrate the infusion according to which of the following assessments?
- A. Stroke volume
- B. Urine output
- C. Blood pressure
- D. Cardiac output
Correct Answer: C
Rationale: The correct answer is C: Blood pressure. When titrating a nitroprusside infusion, monitoring blood pressure is crucial as nitroprusside is a potent vasodilator that directly affects blood pressure. The nurse needs to adjust the infusion rate based on the client's blood pressure response to maintain a therapeutic effect without causing hypotension or hypertension. Monitoring other parameters like stroke volume, cardiac output, or urine output is important for assessing overall cardiac function and fluid status but may not directly guide the titration of a nitroprusside infusion. Blood pressure is the most immediate and direct indicator of the medication's effect on the cardiovascular system.
A nurse is reviewing the laboratory results of a client who is taking amitriptyline. Which of the following laboratory values should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Total bilirubin 1.5 mg/dL
- C. WBC count 5,000/mm²
- D. Hct 44%
Correct Answer: B
Rationale: The correct answer is B: Total bilirubin 1.5 mg/dL. Amitriptyline can affect liver function, leading to increased levels of bilirubin. Elevated bilirubin levels may indicate hepatotoxicity, which can be a serious side effect requiring medical intervention.
A: Potassium level within the normal range is not typically affected by amitriptyline.
C: WBC count within the normal range is not directly influenced by amitriptyline.
D: Hct within the normal range is not typically impacted by amitriptyline.
A nurse in the emergency department is admitting a client who has diabetic ketoacidosis and a blood glucose level of 100 mg/dl. Which of the following interventions should the nurse initiate first?
- A. Potassium chloride 10 mEq/hr
- B. Bicarbonate by IV infusion
- C. Subcutaneous insulin injections
- D. 0.9% sodium chloride 15 mL/kg/hr
Correct Answer: D
Rationale: The correct answer is D - 0.9% sodium chloride 15 mL/kg/hr. In diabetic ketoacidosis, the priority is to correct dehydration and restore intravascular volume. This intervention helps improve tissue perfusion and prevent hypotension. Potassium replacement (Choice A) should not be initiated until adequate urine output is established. Bicarbonate (Choice B) is not routinely recommended due to potential risks such as paradoxical CNS acidosis. Subcutaneous insulin (Choice C) can be initiated once fluid resuscitation is started.
A nurse is teaching a client's partner how to administer an otic medication to the client. Which of the following statements by the client's partner indicates an understanding of the teaching?
- A. I will have my partner tilt their head back while I am instilling the drops.
- B. I will have my partner lie down on their back while I am instilling the drops.
- C. I will pull the pinna upward and outward prior to instilling the drops,
- D. I will make sure the solution is cool prior to instilling the drops
Correct Answer: C
Rationale: Correct Answer: C: "I will pull the pinna upward and outward prior to instilling the drops."
Rationale: Pulling the pinna upward and outward straightens the ear canal, allowing proper administration of the otic medication. This action helps ensure the drops reach the eardrum effectively. Tilted head or lying down can cause the medication to flow out of the ear. Checking the temperature is not necessary for administering otic medications.