Nokea
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
- A. Blood clots
- B. Ecchymotic areas
- C. Jaundice
- D. Infection
Correct Answer: B
Rationale: The normal clotting time is 9 to 12 minutes. A prolonged clotting time suggests a bleeding tendency, so the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a shorter clotting time. Jaundice is related to liver damage or red blood cell breakdown. Infection is associated with low white blood cell counts.
You may also like to solve these questions
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?
- A. Sponge the client's forehead.
- B. Obtain a pulse oximetry reading.
- C. Take the client's vital signs.
- D. Assist the client to a sitting position.
Correct Answer: D
Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (D) improves breathing by reducing preload. Sponging (A), pulse oximetry (B), and vital signs (C) are secondary to positioning.
Which finding would strongly indicate that the cardioversion procedure has been successful?
- A. The client regains consciousness immediately.
- B. Normal sinus cardiac rhythm is restored.
- C. The physical examination of the patient is a second.
- D. The pulse pressure is approximately 40 mm Hg.
Correct Answer: B
Rationale: Restoration of normal sinus rhythm is the primary goal of cardioversion.
Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply.
- A. Instruct the client to stop smoking.
- B. Encourage the client to exercise three (3) days a week.
- C. Teach about coronary vasodilators.
- D. Prepare the client for a carotid endarterectomy.
- E. Eat foods high in monosaturated fats.
Correct Answer: A,B,C
Rationale: Stopping smoking (A), exercising (B), and vasodilators (C) reduce CAD progression. Carotid endarterectomy (D) is for stroke risk, and monounsaturated fats (E) are beneficial but not high amounts.
Which assessment finding is the best indication that oxygen therapy is effective?
- A. The client's face is flushed.
- B. Capillary refill is 6 seconds.
- C. The client states, 'I'm feeling better.'
- D. The apical pulse is less bounding.
Correct Answer: C
Rationale: The client's subjective improvement in symptoms indicates effective oxygen therapy.
Which client would most likely be misdiagnosed for having a myocardial infarction?
- A. A 55-year-old Caucasian male with crushing chest pain and diaphoresis.
- B. A 60-year-old Native American male with an elevated troponin level.
- C. A 40-year-old Hispanic female with a normal electrocardiogram.
- D. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.
Correct Answer: C
Rationale: A 40-year-old Hispanic female with normal ECG (C) is most likely to be misdiagnosed, as women often present atypically and normal ECGs can occur in MI. Typical symptoms (A), elevated troponin (B), and normal CK-MB at 12 hours (D) are less likely to be missed.