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A nurse Is evaluating the laboratory results of four clents. The nurse should report which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- C. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
- D. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A client with a prescription for heparin and an aPTT of 90 seconds indicates that the client's blood is taking too long to clot, which puts the client at risk for bleeding. The aPTT range for a client on heparin therapy is 30-40 seconds, so a result of 90 seconds is significantly elevated and requires immediate attention to prevent bleeding complications.
Summary of other choices:
B: A client with a prescription for heparin and an aPTT of 65 seconds falls within the normal range of 30-40 seconds, so this result does not require immediate reporting.
C: A client with a prescription for warfarin and an INR of 3.0 is within the therapeutic range (2-3) for warfarin therapy, so this result does not require immediate reporting.
D: A client with a prescription for warfarin and an INR of 2.0 is also
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A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.
A nurse is discussing adverse reactions to pain medications in older adult clients with a newly licensed nurse. Which of the following findings should the nurse include as risk factors for an adverse drug reaction? (SATA)
- A. Polypharmacy
- B. Increased rate of absorption
- C. Decreased percentage of body fat
- D. Multiple health problems
Correct Answer: A,C,D,E
Rationale: To determine risk factors for adverse drug reactions in older adults, consider the following:
A: Polypharmacy increases the likelihood of drug interactions and adverse effects.
C: Decreased body fat can affect drug distribution, leading to higher drug concentrations.
D: Multiple health problems may require multiple medications, increasing the risk of adverse reactions.
E: Age-related changes in liver and kidney function can affect drug metabolism and excretion.
Other choices are incorrect because increased rate of absorption does not necessarily increase risk and choices F and G were not provided.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement
for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg per rectum
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg per rectum. Bisacodyl is a stimulant laxative that helps stimulate bowel movements. Given the client's situation of not having a bowel movement for 4 days postpartum with a third-degree perineal laceration, prompt relief is needed to prevent complications such as constipation or increased pressure on the perineal area. Administering Bisacodyl per rectum will provide a faster onset of action compared to oral medications, ensuring timely relief for the client.
Choice B: Magnesium hydroxide is a laxative used for constipation but may not provide immediate relief for the client in this urgent situation.
Choice C: Famotidine is a histamine-2 blocker used for managing stomach acid but is not indicated for addressing constipation.
Choice D: Loperamide is an antidiarrheal medication and is contraindicated in this scenario as it can worsen constipation.
A nurse is assessing for allergies with a client who is scheduled to receive the influenza vaccine. Which of the following allergies should the nurse report to the provider as a possible contraindication to receiving the vaccine?
- A. Eggs
- B. Shellfish
- C. Peanuts
- D. Milk
Correct Answer: A
Rationale: The correct answer is A: Eggs. Influenza vaccines are typically produced using eggs, so individuals with egg allergies may have an allergic reaction to the vaccine. Reporting this allergy to the provider is crucial to avoid potential adverse reactions. Shellfish, peanuts, and milk allergies are not contraindications for receiving the influenza vaccine. Summary: Eggs are the correct answer due to the vaccine production method; shellfish, peanuts, and milk allergies are not relevant in this context.
A nurse is teaching a client about oral contraceptive. Which of the following information should the nurse include in the teaching?
- A. Abdominal pain is an expected adverse effect of oral contraceptives
- B. It can take up to 1 year to become pregnant after stopping an oral contraceptive
- C. Some herbal supplements can decrease the effectiveness of an oral contraceptive
- D. A pelvic examination is needed prior to starting an oral contraceptive
Correct Answer: C
Rationale: The correct answer is C: Some herbal supplements can decrease the effectiveness of an oral contraceptive. The nurse should include this information in the teaching to ensure the client understands potential interactions. Herbal supplements like St. John's Wort can reduce the effectiveness of oral contraceptives by increasing their metabolism. This can lead to contraceptive failure and unintended pregnancy. Option A is incorrect because abdominal pain is not an expected adverse effect of oral contraceptives. Option B is incorrect as fertility typically returns quickly after stopping oral contraceptives, not taking up to a year. Option D is incorrect as a pelvic examination is not always necessary before starting oral contraceptives.