Nokea
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. LDL
- B. INR
- C. BUN
- D. Hct
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.
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A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Empty the urine into a sterile container labeled with the client identifiers.
- B. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- E. Clamp the catheter tubing distal to the sampling port for 15 min.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (D), aspirate (C), transfer (A), document (B) ensures sterility and proper procedure.
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
- A. Leave the television on in the client's room
- B. Raise all four side rails while the client is in bed.
- C. Move the overbed table away from the bed.
- D. Apply a motion sensor mat to the client's bed
Correct Answer: D
Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Temperature 37.3°C (99.1°F)
- B. Changed mental status
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: B
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often due to systemic effects of infection. The temperature and WBC count are within normal limits, and diminished reflexes are unrelated to a UTI.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10⁶ µL (4.2 to 5.4 x 10⁶ µL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Platelet count 180,000/mm³ (150,000 to 400,000/mm³)
Vitamin B₁₂ 159 pg/mL (160 to 950 pg/mL)
1030:
Stool for fecal occult blood negative
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following instructions should the nurse include?
- A. Take an antacid within 30 min after medication administration.
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C.
- D. Increase intake of milk and dairy products.
- E. Take the medication on an empty stomach.
Correct Answer: C
Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Blister integrity (A), pain relief with ibuprofen (C), and cool water (D) are correct. Ice can worsen damage, and open air isn't recommended initially.