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Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
- A. White blood cell count.
- B. Prothrombin time (PT) and International Normalized Ratio (INR).
- C. Hemoglobin and hematocrit.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.
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A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
- A. Check the client's blood glucose level.
- B. Decrease the rate of TPN infusion.
- C. Administer an antiemetic as prescribed.
- D. Check the client's TPN bag for solution accuracy.
Correct Answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
A client reports dizziness when standing up quickly. What advice should the nurse give?
- A. Encourage the client to drink more fluids.
- B. Change positions slowly to prevent dizziness.
- C. Report the symptom to the healthcare provider immediately.
- D. Limit physical activity to avoid triggering dizziness.
Correct Answer: B
Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.
The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?
- A. All of the above
- B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
- C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
Correct Answer: A
Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.
The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?
- A. Encourage the client to ambulate
- B. Apply a warm compress to the left leg
- C. Elevate the client's left leg
- D. Administer a prescribed anticoagulant
Correct Answer: C
Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.
A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?
- A. Limit sodium intake to 2 grams per day.
- B. Choose fresh fruits and vegetables.
- C. Drink at least 8 glasses of water daily.
- D. Avoid processed foods and canned soups.
Correct Answer: D
Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.