Nokea
Receiving a report that Mr. K.'s prothrombin time (PT) is 4-4.5 times normal, your nursing action would be to
- A. call Mr. K.'s physician to report the PT
- B. stop the heparin infusion
- C. increase the heparin infusion by 10 mg/hr
- D. nothing, as the value is therapeutic
Correct Answer: A
Rationale: An elevated PT indicates potential bleeding risk, necessitating immediate medical review.
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What is a procedure to remove fluid or air from the pleural space to help a patient breathe easier?
- A. Thoracentesis
- B. Bronchoscopy
- C. Chest X-ray
- D. CT scan
Correct Answer: A
Rationale: Thoracentesis is the correct answer because it is a procedure used to remove fluid or air from the pleural space, which can help a patient breathe easier. The steps involved in thoracentesis include identifying the location for insertion, numbing the area with local anesthesia, inserting a needle or catheter into the pleural space, draining the fluid or air, and monitoring the patient for any complications.
Summary:
- B: Bronchoscopy is a procedure used to visualize the airways and diagnose lung conditions, not to remove fluid or air from the pleural space.
- C: Chest X-ray is an imaging test used to visualize the chest area and diagnose various conditions, but it does not involve removing fluid or air from the pleural space.
- D: CT scan is an imaging test that provides detailed images of the internal structures of the body, but it is not a procedure for removing fluid or air from the pleural space.
What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?
- A. Autoimmune disease
- B. Infectious disease
- C. Allergic reaction
- D. Degenerative disease
Correct Answer: A
Rationale: The correct answer is A: Autoimmune disease. In autoimmune diseases, the immune system mistakenly attacks the body's tissues, leading to inflammation and damage. This occurs due to a breakdown in immune tolerance, resulting in the immune system targeting self-antigens. This leads to chronic inflammation and tissue damage. In contrast, infectious diseases are caused by pathogens, allergic reactions are responses to harmless substances, and degenerative diseases involve the gradual deterioration of tissues over time. Therefore, autoimmune disease best fits the description provided in the question.
The client is on nitroglycerin patches. What should the nurse include in the client's education?
- A. Rotate the application site with each new patch.
- B. Apply the patch at the same time each day.
- C. Leave the patch on for 24 hours, then remove it for 12 hours before applying a new one.
- D. Apply the patch to the same site each time.
Correct Answer: A
Rationale: The correct answer is A: Rotate the application site with each new patch. This is important to prevent skin irritation and tolerance development. Rotating sites ensures consistent drug absorption and reduces the risk of skin reactions. Applying the patch at the same site each time (choice D) can lead to localized skin irritation. Applying the patch at the same time each day (choice B) is not as crucial as rotating sites. Leaving the patch on for 24 hours and then removing it for 12 hours (choice C) can disrupt the therapeutic effect of the medication.
The nurse is giving digoxin to a client. What is the most important parameter to check before administration?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: A
Rationale: Step 1: Digoxin is primarily used to treat heart conditions.
Step 2: Heart rate is crucial as digoxin can affect the heart rhythm.
Step 3: Monitoring heart rate ensures safety and effectiveness of digoxin.
Step 4: Blood pressure, respiratory rate, and oxygen saturation are important but not as directly impacted by digoxin.
During which process does coronary artery blood flow to the myocardium occur during diastole, when coronary vascular resistance is reduced?
- A. Coronary perfusion pressure
- B. Coronary vascular resistance
- C. Diastolic filling
- D. Ventricular ejection
Correct Answer: A
Rationale: The correct answer is A: Coronary perfusion pressure. Coronary perfusion pressure is the pressure gradient that drives blood flow through the coronary arteries into the myocardium during diastole when the coronary vascular resistance is reduced. This pressure gradient is essential for delivering oxygen and nutrients to the heart muscle when it is relaxed and filling with blood. During diastole, the coronary arteries receive blood flow predominantly due to the pressure difference between the aortic diastolic pressure and the pressure in the coronary vasculature.
Summary of why the other choices are incorrect:
B: Coronary vascular resistance - This factor is reduced during diastole, allowing for increased blood flow, but it does not directly drive blood flow to the myocardium.
C: Diastolic filling - This refers to the filling of blood into the ventricles of the heart, not specifically the flow of blood through the coronary arteries.
D: Ventricular ejection - This occurs during systole when the ventricles contract