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A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?
- A. INR 1.8
- B. Hemoglobin 14 g/dL
- C. Platelets 175,000/mm³
- D. Potassium 3.8 mEq/L
Correct Answer: A
Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.
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What is the priority nursing intervention for a patient experiencing a myocardial infarction?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Administer morphine
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?
- A. I will take warfarin every other day.
- B. I will eat more leafy green vegetables while taking warfarin.
- C. I will use a soft toothbrush while taking warfarin.
- D. I will have my INR checked regularly while taking warfarin.
Correct Answer: B
Rationale: The correct answer is B. Eating more leafy green vegetables can increase vitamin K intake, which may reduce the effectiveness of warfarin. This can lead to fluctuations in the International Normalized Ratio (INR) levels, affecting the medication's efficacy. Choices A, C, and D are correct statements. Taking warfarin every other day, using a soft toothbrush to prevent gum bleeding, and having regular INR checks are all appropriate and important actions when taking warfarin.
A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?
- A. Take this medication in the evening before bed.
- B. Take this medication on an empty stomach.
- C. Take this medication with a full glass of milk.
- D. Take this medication with an antacid if you experience indigestion.
Correct Answer: B
Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.
A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include in the plan of care?
- A. Place the client in the supine position.
- B. Perform chest percussion every 4 hours.
- C. Administer oxygen via nasal cannula.
- D. Limit fluid intake to 1,500 mL/day.
Correct Answer: B
Rationale: The correct intervention for a client with pneumonia is to perform chest percussion every 4 hours. Chest percussion helps loosen secretions and improve airway clearance in clients with pneumonia. Placing the client in the supine position can worsen breathing, so it is incorrect. Administering oxygen via nasal cannula is a common intervention for clients with respiratory issues but is not specific to pneumonia. Limiting fluid intake to 1,500 mL/day may not be appropriate as pneumonia can lead to dehydration, so it is not the priority intervention.
A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct Answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.