Nokea
A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the therapeutic INR range for this medication?
- A. 2--3
- B. 3--1
- C. 8--4
- D. 0.5-2.5
Correct Answer: A
Rationale: The therapeutic INR range is 2-3. It may be slightly higher if a patient is at a high risk for clot formation (ex: up to 4.5)
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The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?
- A. Standard Precautions.
- B. Contact Precautions.
- C. Droplet Precautions.
- D. Airborne Precautions.
Correct Answer: D
Rationale: TB is transmitted via airborne droplets, requiring airborne precautions (D) with negative-pressure rooms. Standard (A), contact (B), and droplet (C) are insufficient.
The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?
- A. Cool extremity
- B. Decreases pulses
- C. Redness
- D. Pain
- E. Warm extremity
- F. Swelling
- G. Cyanosis
Correct Answer: C,D,E,F
Rationale: Signs and symptoms of a DVT include: redness, swelling, warm extremity, pain, positive Homan's Sign, and swelling (which can be unilateral...meaning there is more swelling in one extremity compared to the other).
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
- A. Assist the client into a sitting position at 90 degrees.
- B. Administer oxygen at six (6) LPM via nasal cannula.
- C. Monitor vital signs with the client sitting upright.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sitting upright (A) improves lung expansion in COPD distress, a priority. Oxygen (B), vitals (C), and notification (D) follow to support oxygenation and communication.
When the client asks why the physician prescribed this particular cough medicine, the nurse correctly responds that the guaifenesin liquefies mucus while the codeine is responsible for which action?
- A. Relieving discomfort
- B. Dilating the bronchi
- C. Suppressing coughing
- D. Reducing inflammation
Correct Answer: C
Rationale: Codeine in cough syrup acts as an antitussive, suppressing the cough reflex to reduce coughing episodes.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.