Nokea
The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR results on the client's chart since admission three (3) days ago. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Notify the health-care provider immediately.
- C. Obtain the PT/PTT and INR prior to administering the medication.
- D. Hold the medication until the HCP makes rounds.
Correct Answer: A
Rationale: LMWH (e.g., enoxaparin) does not require PT/PTT/INR monitoring (A); it’s administered as ordered. Notifying HCP (B), obtaining labs (C), or holding (D) are unnecessary.
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Which assessment finding indicates a worsening condition in a client with pericarditis?
- A. Muffled heart sounds
- B. Heart rate of 80 beats per minute
- C. Blood pressure of 120/80 mmHg
- D. Mild chest discomfort
Correct Answer: A
Rationale: Muffled heart sounds suggest pericardial effusion or cardiac tamponade, indicating worsening pericarditis.
The client diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.
Which teaching point should the nurse include for a client with coronary artery disease? Select all that apply.
- A. Exercise regularly as tolerated.
- B. Avoid all fats in the diet.
- C. Manage stress effectively.
- D. Take medications as prescribed.
- E. Monitor for chest pain.
- F. Limit physical activity.
Correct Answer: A,C,D,E
Rationale: Regular exercise, stress management, medication adherence, and monitoring for chest pain reduce complications in coronary artery disease.
Which teaching point should the nurse include for a client with cardiomyopathy? Select all that apply.
- A. Monitor for signs of heart failure.
- B. Avoid alcohol consumption.
- C. Take medications as prescribed.
- D. Engage in high-intensity exercise.
- E. Report sudden weight gain.
- F. Limit fluid intake as advised.
Correct Answer: A,B,C,E,F
Rationale: Monitoring heart failure signs, avoiding alcohol, adhering to medications, reporting weight gain, and limiting fluids prevent complications.
Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?
- A. Absent bilateral pedal pulses.
- B. Complaints of pain at the site of the incision.
- C. Distended, tender abdomen.
- D. An elevated temperature of 100°F.
Correct Answer: A
Rationale: Absent pedal pulses (A) suggest graft occlusion, a surgical emergency. Incisional pain (B), distension (C), and low-grade fever (D) are expected or less urgent.