Nokea
The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Increased respiratory rate.
- B. Decreased oxygen saturation.
- C. Clear lung sounds.
- D. Elevated white blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.
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The nurse is planning care for a client with cirrhosis of the liver. Which intervention should the nurse include to reduce the risk of bleeding?
- A. Monitor for signs of infection.
- B. Limit the client's dietary protein intake.
- C. Administer vitamin K as prescribed.
- D. Encourage the client to increase fluid intake.
Correct Answer: C
Rationale: Correct Answer: C - Administer vitamin K as prescribed.
Rationale:
1. Cirrhosis impairs liver function, leading to decreased synthesis of clotting factors, increasing the risk of bleeding.
2. Vitamin K is essential for synthesizing clotting factors; administering it helps improve clotting ability.
3. Monitoring for infection (A) is important but does not directly address the clotting issue.
4. Limiting protein intake (B) is not necessary for bleeding prevention in cirrhosis.
5. Encouraging fluid intake (D) is important for overall health but does not specifically reduce the risk of bleeding.
A client with chronic renal failure is prescribed erythropoietin (Epogen). Which outcome indicates that the medication is effective?
- A. Increased urine output.
- B. Improved hemoglobin levels.
- C. Decreased blood pressure.
- D. Stable potassium levels.
Correct Answer: B
Rationale: The correct answer is B: Improved hemoglobin levels. Erythropoietin stimulates the production of red blood cells, leading to an increase in hemoglobin levels. This is the desired outcome in a client with chronic renal failure, as it helps alleviate anemia.
Choice A is incorrect because increased urine output is not a direct indicator of erythropoietin effectiveness. Choice C is incorrect as erythropoietin does not directly impact blood pressure. Choice D is incorrect because stable potassium levels are not a primary outcome of erythropoietin therapy in chronic renal failure.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory test should the nurse monitor to determine the effectiveness of the medication?
- A. Platelet count.
- B. Prothrombin time (PT) and international normalized ratio (INR).
- C. Activated partial thromboplastin time (aPTT).
- D. Fibrinogen level.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and international normalized ratio (INR). Warfarin works by inhibiting vitamin K-dependent clotting factors, affecting the PT and INR. Monitoring these levels helps assess the effectiveness of warfarin in preventing clot formation. Platelet count (A) assesses clotting ability but not the effectiveness of warfarin. Activated partial thromboplastin time (C) assesses intrinsic pathway clotting factors, not affected by warfarin. Fibrinogen level (D) assesses the final step of clot formation, not specific to warfarin effectiveness.
A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
- A. Check the client's blood glucose level.
- B. Administer 10 units of insulin.
- C. Give the client a high-protein snack.
- D. Measure the client's blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Check the client's blood glucose level. The client's symptoms are indicative of hypoglycemia, which is a common complication in diabetes mellitus. Checking the blood glucose level will confirm the diagnosis and guide appropriate interventions. Administering insulin (B) could worsen the hypoglycemia. Giving a high-protein snack (C) may help raise blood sugar levels but should be done after confirming the diagnosis. Measuring blood pressure (D) is not the priority in this situation.