Nokea
The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?
- A. Monitoring the client's vital signs every 4 hours
- B. Assessing the puncture site for bleeding
- C. Encouraging the client to ambulate early to prevent complications
- D. Providing the client with fluids to flush out the contrast dye
Correct Answer: B
Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring the puncture site helps ensure early intervention and prevent further complications, making it the priority assessment in this situation.
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In monitoring the effectiveness of warfarin therapy for a client with a history of atrial fibrillation, which laboratory value should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT)
- B. Prothrombin time (PT) and international normalized ratio (INR)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: B
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are crucial laboratory values to monitor the effectiveness of warfarin therapy in clients with atrial fibrillation. These values help ensure that the client is within the therapeutic range and that the anticoagulant effect of warfarin is appropriate.
A client with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which sign of theophylline toxicity?
- A. Drowsiness
- B. Bradycardia
- C. Nausea
- D. Constipation
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is receiving intravenous heparin therapy for the treatment of deep vein thrombosis (DVT). Which laboratory test result should the LPN/LVN monitor to ensure the client is receiving a therapeutic dose?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct laboratory test result that the LPN/LVN should monitor to ensure the client is receiving a therapeutic dose of heparin therapy is the activated partial thromboplastin time (aPTT). The aPTT test is specifically used to monitor heparin therapy, ensuring that the dose administered is within the therapeutic range. Monitoring aPTT helps to prevent complications such as bleeding or clot formation by maintaining the appropriate anticoagulant effect of heparin.
A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the LPN/LVN expect to assist with first?
- A. Administer a diuretic as prescribed.
- B. Place the client in a high Fowler's position.
- C. Prepare the client for intubation.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: In a client with pulmonary edema, placing them in a high Fowler's position is the priority intervention. This position helps to improve ventilation and oxygenation by decreasing venous return, reducing the workload on the heart, and facilitating fluid redistribution from the lungs. It is crucial to optimize respiratory function and oxygenation before considering other interventions like administering medications, preparing for intubation, or inserting a urinary catheter.
The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?
- A. Blood glucose
- B. Serum sodium
- C. Serum potassium
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.