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A patient who is taking warfarin (Coumadin) 5 mg daily has an international normalized ratio (INR) of 2.5. It is time to administer the next dose of Coumadin. What should the nurse do?
- A. Notify the physician STAT.
- B. Hold the dose of Coumadin.
- C. Prepare to administer vitamin K.
- D. Administer the daily Coumadin as ordered.
Correct Answer: D
Rationale: The correct answer is D: Administer the daily Coumadin as ordered. A therapeutic INR range for patients on warfarin is typically between 2-3. A patient with an INR of 2.5 is within this range, indicating that their blood is adequately anticoagulated. Therefore, the next dose of Coumadin should be administered as prescribed to maintain the therapeutic effect. Holding the dose (B) may lead to subtherapeutic anticoagulation, and notifying the physician (A) is not necessary as the INR is within range. Administering vitamin K (C) is indicated for patients with a high INR and signs of bleeding, which is not the case here.
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A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patient's care plan?
- A. Protective isolation and vigilant use of standard precautions
- B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
- C. Including the family in planning the patient's activities of daily living
- D. Monitoring and treating the patient's pain
Correct Answer: A
Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. This is the priority because patients with AML undergoing induction therapy are immunocompromised and at high risk for infection. Isolating the patient and using standard precautions help prevent exposure to pathogens.
B: Providing a high-calorie, low-texture diet and oral hygiene is important but not the priority as infection control takes precedence.
C: Including the family in planning activities of daily living is beneficial for holistic care but not the priority compared to infection prevention.
D: Monitoring and treating pain is essential, but in this case, infection prevention is the priority due to the patient's immunocompromised state.
A nurse is assessing a dark-skinned client for pallor. What action is best?
- A. Assess the conjunctiva of the eye.
- B. Have the client open the hand widely.
- C. Look at the roof of the client's mouth.
- D. Palpate for areas of mild swelling.
Correct Answer: A
Rationale: The correct answer is A because assessing the conjunctiva of the eye is the best way to assess pallor in dark-skinned individuals. Pallor is difficult to detect on dark skin due to increased melanin. The conjunctiva is a mucous membrane that can show pallor regardless of skin tone. Choices B, C, and D are incorrect because examining the hand, mouth, or palpating for swelling are not reliable methods for assessing pallor in dark-skinned individuals.
The pathophysiology of venous thrombosis is often explained by Virchow's triad, which includes hypercoagulability, endothelial injury, and venous stasis. Based on Virchow's triad and your knowledge of risk factors for thrombosis, which of the following pediatric patients has the greatest risk of hospital-acquired venous thromboembolism?
- A. 3-day-old full-term infant admitted to hospital pediatrics for hyperbilirubinemia
- B. 6-month-old male admitted to the infectious disease unit for respiratory syncytial virus
- C. Ex-28 week premature infant, requiring NICU-level care for necrotizing enterocolitis
- D. 7-year-old male with acute lymphoblastic leukemia receiving maintenance chemotherapy admitted to hematology/oncology unit for fever and neutropenia
Correct Answer: C
Rationale: The correct answer is C because the ex-28 week premature infant requiring NICU-level care for necrotizing enterocolitis has the greatest risk of hospital-acquired venous thromboembolism. Premature infants have inherent hypercoagulability due to immature coagulation factors and increased risk of endothelial injury from central lines or catheters. Necrotizing enterocolitis further increases the risk of venous stasis due to decreased gut perfusion.
Choice A: The 3-day-old full-term infant admitted for hyperbilirubinemia is less likely to have significant risk factors for thrombosis compared to a premature infant with necrotizing enterocolitis.
Choice B: The 6-month-old male admitted for respiratory syncytial virus is less likely to have prolonged immobilization or other significant risk factors compared to a premature infant in the NICU.
Choice D: The 7-year-old male with acute lymphoblastic leukemia has a higher risk of thromb
A patient receiving blood complains of dyspnea. The nurse auscultates the patient's lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect?
- A. Urticarial
- B. Hemolytic
- C. Anaphylactic
- D. Circulatory overload
Correct Answer: D
Rationale: The correct answer is D: Circulatory overload. Dyspnea and crackles post-transfusion indicate fluid overload, not an immune response. Step 1: Rule out urticarial (itching/rash) and anaphylactic (rapid onset, hypotension) reactions due to the absence of these symptoms. Step 2: Hemolytic reactions involve destruction of red blood cells, leading to hemoglobinuria and shock. Step 3: Circulatory overload results from an excessive volume of blood given, leading to pulmonary edema and crackles. In this case, the symptoms align with circulatory overload, making it the most likely reaction.
Heparin is an anticoagulant produced by the basophils. The most likely mechanism heparin prevents blood clotting is by
- A. Inhibiting the formation of vitamin K-dependent clotting factors
- B. Preventing the activation of platelets
- C. Preventing the aggregation of platelets
- D. Binding to antithrombin III to inactivate thrombin
Correct Answer: D
Rationale: The correct answer is D because heparin binds to antithrombin III, enhancing its ability to inactivate thrombin. This prevents the conversion of fibrinogen to fibrin, thereby inhibiting blood clot formation. Choices A and B are incorrect because heparin does not affect vitamin K-dependent clotting factors or platelet activation. Choice C is incorrect because heparin does not directly prevent platelet aggregation.