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A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most
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Which of the following statements by the client indicates an understanding of the teaching?
- A. I should keep the medication in the original container.
- B. I should replace any unused medication every 6 months.
- C. I can store the medication in the refrigerator.
- D. I can crush the medication and mix with applesauce.
Correct Answer: A
Rationale: The correct answer is A because keeping medication in the original container ensures proper identification, dosage, and expiration monitoring. Choice B is incorrect as replacing unused medication every 6 months may lead to waste. Choice C is incorrect as not all medications should be stored in the refrigerator. Choice D is incorrect as crushing medication may alter its effectiveness or cause harm. It is important for the client to understand the importance of following specific storage instructions provided with the medication, making choice A the most appropriate response.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications
- B. Educating clients about contraindications to specific immunizations
- C. Helping clients understand health screenings covered by their insurance plans
- D. Providing clients with information about the benefits of exercise
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and improving the quality of life for individuals already diagnosed with a disease. In this case, reminding clients to take medications helps prevent complications and progression of HIV. The other choices are incorrect because: B is an example of primary prevention as it aims to prevent the occurrence of a disease; C is related to secondary prevention as it involves early detection and prevention of complications; D is a form of health promotion rather than prevention.
Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. Bradypnea, or slow breathing, is a critical finding that can indicate respiratory compromise and potentially lead to respiratory failure. It requires immediate attention to prevent further deterioration.
Constipation (A) is important but not as urgent as addressing a respiratory issue. Sedation (B) and euphoria (D) are side effects that may need monitoring but do not pose immediate threats to the patient's health.
In summary, addressing bradypnea is the priority to ensure the patient's respiratory function and prevent a life-threatening situation.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.