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The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
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Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
Which signs/symptoms would the nurse expect to find when assessing a client diagnosed with subclavian steal syndrome?
- A. Complaints of arm tiredness with exertion.
- B. Complaints of shortness of breath while resting.
- C. Jugular vein distention when sitting at a 35-degree angle.
- D. Dilated blood vessels above the nipple line.
Correct Answer: A
Rationale: Subclavian steal syndrome causes arm ischemia due to subclavian artery occlusion, leading to arm tiredness with exertion (A). Shortness of breath (B), JVD (C), and dilated vessels (D) are not typical.
The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.