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The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate?
- A. Protamine sulfate, an anticoagulant antidote.
- B. Heparin sodium, an anticoagulant.
- C. Lovenox, a low molecular weight anticoagulant.
- D. Vitamin K, an anticoagulant agonist.
Correct Answer: D
Rationale: Warfarin toxicity causes bleeding; vitamin K (D) reverses it. Protamine (A) reverses heparin, heparin/Lovenox (B, C) worsen bleeding.
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Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenic purpura (ITP)?
- A. Petechiae on the anterior chest, arms, and neck.
- B. Capillary refill of less than three (3) seconds.
- C. An enlarged spleen.
- D. Pulse oximeter reading of 95%.
Correct Answer: A
Rationale: ITP causes low platelets, leading to petechiae (A). Capillary refill (B) is normal, splenomegaly (C) is not primary, and SpO2 95% (D) is normal.
Which laboratory result would the nurse expect in the client diagnosed with DIC?
- A. A decreased prothrombin time.
- B. A low fibrinogen level.
- C. An increased platelet count.
- D. An increased white blood cell count.
Correct Answer: B
Rationale: DIC consumes clotting factors, lowering fibrinogen (B). PT is prolonged (A), platelets decrease (C), and WBCs (D) are nonspecific.
The client diagnosed with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client?
- A. Take Imodium, an antidiarrheal, over-the-counter (OTC) for diarrhea.
- B. Limit exercise for several weeks until a tolerance is achieved.
- C. The stools may be very dark, and this can mask blood.
- D. Eat only red meats and organ meats for protein.
Correct Answer: C
Rationale: Ferrous gluconate darkens stools (C), potentially masking GI bleeding. Imodium (A) is premature, exercise (B) is encouraged, and diet (D) should be varied, not meat-only.
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
The nurse is assisting the HCP with a bone marrow biopsy. Which intervention postprocedure has priority?
- A. Apply pressure to site for five (5) to 10 minutes.
- B. Medicate for pain with morphine slow IVP.
- C. Maintain head of bed in high Fowler’s position.
- D. Apply oxygen via nasal cannula at five (5) L/min.
Correct Answer: A
Rationale: Applying pressure for 5–10 minutes (A) prevents bleeding post-biopsy, a priority. Pain meds (B), HOB (C), and oxygen (D) are secondary or unrelated.