Nokea
The client diagnosed with a deep vein thrombosis is prescribed heparin via continuous infusion. The client's laboratory data are: PT 12.2 aPTT 48 Control 1.4 Control 32 INR 1 Based on the laboratory results, which intervention should the nurse implement?
- A. Request a change of medication to a subcutaneous anticoagulant.
- B. Administer AquaMephyton (vitamin K) IM.
- C. Have the dietary department remove all green, leafy vegetables from the trays.
- D. Administer the IV as ordered.
Correct Answer: D
Rationale: aPTT 48 (therapeutic 1.5–2× control 32 = 48–64) is within range; continue heparin as ordered (D). Subcutaneous (A) is inappropriate, vitamin K (B) reverses heparin, and diet (C) is for warfarin.
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Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain exacerbations will not occur in the summer.
- B. Use nicotine gum to help quit smoking.
- C. Wear extra-warm clothing during cold exposure.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: C
Rationale: Cold triggers Raynaud’s; wearing warm clothing (C) prevents vasospasm. Exacerbations occur in summer (A), nicotine gum (B) still delivers nicotine (harmful), and sunlight (D) is irrelevant.
Which dietary recommendation should the nurse provide to a client with coronary artery disease?
- A. Eat foods high in saturated fats.
- B. Limit intake of fruits and vegetables.
- C. Choose lean proteins and whole grains.
- D. Increase consumption of sugary drinks.
Correct Answer: C
Rationale: Lean proteins and whole grains reduce cholesterol and improve heart health.
The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
The client with heart failure reports fatigue. Which action should the nurse take first?
- A. Encourage bedrest all day.
- B. Assess oxygen saturation.
- C. Administer a diuretic.
- D. Increase fluid intake.
Correct Answer: B
Rationale: Fatigue in heart failure may indicate hypoxemia, so assessing oxygen saturation is the priority.
Which finding should the nurse report immediately in a client with a deep vein thrombosis (DVT)?
- A. Warm, red skin over the affected area
- B. Mild leg pain
- C. Heart rate of 80 beats per minute
- D. Blood pressure of 130/85 mmHg
Correct Answer: A
Rationale: Warm, red skin over the affected area may indicate worsening DVT or complications like thrombophlebitis, requiring immediate attention.