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. Hct
- B. INR
- C. BUN
- D. LDL
Correct Answer: B
Rationale: INR (International Normalized Ratio) is monitored for warfarin therapy to assess clotting time and ensure therapeutic anticoagulation levels.
You may also like to solve these questions
A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.
A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Encourage socialization as a distractor when the client becomes agitated.
- B. Limit instructions to two steps at a time.
- C. Vary the staff providing care for the client
- D. Encourage independence in ADLs.
Correct Answer: B
Rationale: Limiting instructions to two steps accommodates cognitive decline in Alzheimer's, enhancing comprehension and reducing frustration.
A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?
- A. Ginkgo biloba
- B. Flaxseed powder
- C. Probiotics
- D. Echinacea
Correct Answer: A
Rationale: Ginkgo biloba can increase the risk of bleeding when taken with enoxaparin, an anticoagulant, and should be reported to the provider.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Which of the following actions should the nurse take?
- A. Prepare to obtain a wound culture.
- B. Restrict fluid intake.
- C. Administer an analgesic
- D. Prepare to administer an antibiotic
- E. Initiate supplemental oxygen.
Correct Answer: A,C,D
Rationale: Wound culture assesses for infection, analgesics manage pain, and antibiotics treat potential infection post-fasciotomy; fluid restriction and oxygen are not indicated.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.