Nokea
A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?
- A. INR 2.0
- B. Platelet count 150,000/mm3
- C. aPTT 60 seconds
- D. WBC count 8,000/mm3
Correct Answer: C
Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.
You may also like to solve these questions
A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?
- A. Obtain the client's vital signs.
- B. Ensure the client's IV access is patent.
- C. Prime the IV tubing with 0.9% sodium chloride.
- D. Verify the client's identity.
Correct Answer: D
Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.
A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?
- A. Flush the tube with 30 mL of sterile water before each feeding
- B. Administer the feeding using a large-bore syringe
- C. Keep the head of the bed elevated to 15 degrees
- D. Replace the feeding bag every 24 hours
Correct Answer: A
Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.
A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?
- A. Ammonia 75 mcg/dL
- B. Sodium 142 mEq/L
- C. Calcium 9.5 mg/dL
- D. Bilirubin 2.5 mg/dL
Correct Answer: D
Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.
A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?
- A. Administer oxygen and assess the client's response.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the IV infusion.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.
A client with a new diagnosis of Graves' disease and a prescription for propylthiouracil (PTU) is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should report a sore throat to my provider.
- B. I will need to take this medication for the rest of my life.
- C. This medication increases my risk for infection.
- D. This medication decreases my appetite.
Correct Answer: C
Rationale: The correct answer is C because propylthiouracil (PTU) can increase the risk of infection. Therefore, the client should be aware that this medication may compromise their immune system, making them more susceptible to infections. Reporting any signs of infection promptly to the provider is crucial for timely intervention and management. Choices A, B, and D are incorrect because reporting a sore throat, assuming lifelong medication intake, or experiencing decreased appetite are not directly related to the medication's side effects or risks.