Nokea
A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?
- A. aPTT of 38 seconds
- B. Hemoglobin of 15 g/dL
- C. Platelet count of 80,000/mm3
- D. INR of 1.0
Correct Answer: C
Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.
You may also like to solve these questions
A client who is at 10 weeks of gestation and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include?
- A. You should eat crackers before getting out of bed.
- B. You should drink ginger ale with your meals.
- C. You should lie down for 30 minutes after eating.
- D. You should avoid eating between meals.
Correct Answer: A
Rationale: The correct answer is A: 'You should eat crackers before getting out of bed.' Eating crackers before getting out of bed can help reduce nausea and vomiting during pregnancy. This recommendation helps in stabilizing blood sugar levels before fully waking up. Choice B is incorrect because ginger ale may exacerbate nausea due to its carbonation. Choice C is incorrect as lying down after eating can worsen symptoms of nausea. Choice D is incorrect as avoiding eating between meals can lead to low blood sugar levels, worsening nausea and vomiting.
A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Hypotension.
- C. Diaphoresis.
- D. Hyperactive bowel sounds.
Correct Answer: C
Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.
A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You should expect your urine to turn orange while taking this medication.
- C. This medication can cause you to gain weight.
- D. Take this medication with food to reduce gastrointestinal discomfort.
Correct Answer: D
Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.
A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). What recommendation should be included?
- A. Consume foods high in bran fiber.
- B. Increase intake of milk products.
- C. Sweeten foods with fructose corn syrup.
- D. Increase intake of foods high in gluten.
Correct Answer: A
Rationale: The correct answer is A: Consume foods high in bran fiber. Bran fiber is recommended for clients with IBS as it promotes regularity and helps reduce symptoms. Choices B, C, and D are incorrect. Increasing milk products may exacerbate symptoms in some individuals with IBS due to lactose intolerance. Sweetening foods with fructose corn syrup can worsen symptoms as it is a type of sugar that can lead to gastrointestinal discomfort. Increasing intake of foods high in gluten is not recommended for individuals with IBS, especially those with gluten sensitivity, as it may trigger or worsen symptoms.
A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.