Nokea
A patient is receiving continuous IV Heparin for anticoagulation therapy for the treatment of a DVT. In order for this medication to have a therapeutic effect on the patient, the aPTT should be?
- A. 0.5-2.5 times the normal value range
- B. 2-3 times the normal value range
- C. 1.5-2.5 times the normal value range
- D. 1-3.5 times the normal value range
Correct Answer: C
Rationale: An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. If the aPTT is too low, blood clots can form. If the aPTT is too high, bleeding can occur.
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Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply.
- A. Impaired gas exchange.
- B. Inability to tolerate temperature extremes.
- C. Activity intolerance.
- D. Inability to cope with changes in roles.
- E. Alteration in nutrition.
Correct Answer: A,C,D,E
Rationale: COPD causes impaired gas exchange (A), activity intolerance (C), role changes (D), and nutritional issues (E) from energy demands. Temperature intolerance (B) is not primary.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
Which instruction regarding the prescribed medication is most appropriate to tell this client?
- A. Do not take the drug more frequently than prescribed.
- B. Avoid taking the medication before going to sleep.
- C. Drink more fluid throughout the day.
- D. Warm the cough syrup to make it more palatable.
Correct Answer: C
Rationale: Drinking more fluids enhances the expectorant effect of guaifenesin, helping to thin and expel mucus.
If the client develops a severe allergic reaction, which drug should the nurse have available?
- A. Codeine sulfate
- B. Morphine sulfate (Roxanol)
- C. Dopamine (Intropin)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Epinephrine is the first-line treatment for severe allergic reactions (anaphylaxis) as it reverses airway constriction and stabilizes blood pressure.
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.