Nokea
The nurse evaluates the effects of warfarin by monitoring what lab test?
- A. Platelet count.
- B. Activated thromboplastin time (APT).
- C. Red blood count (RBC).
- D. Prothrombin time (PT) and international normalized ratio (INR).
Correct Answer: D
Rationale: The correct answer is D: Prothrombin time (PT) and international normalized ratio (INR). Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Monitoring PT and INR levels helps assess the effectiveness and safety of warfarin therapy. PT measures the time it takes for blood to clot, while INR standardizes PT results. Platelet count (A) assesses clot formation ability, not warfarin effects. APT (B) primarily evaluates the intrinsic pathway of coagulation. RBC count (C) measures oxygen-carrying capacity, unrelated to warfarin effects.
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The nurse is caring for a patient that has seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as:
- A. A sign of poor self-care.
- B. A drug interaction with aspirin.
- C. An adverse effect of the phenytoin.
- D. A symptom of hepatotoxicity.
Correct Answer: C
Rationale: The correct answer is C: An adverse effect of phenytoin. Phenytoin is an antiepileptic drug known to cause gingival hyperplasia, leading to reddened and bleeding gums. This is a common side effect of phenytoin due to its effect on gingival tissues. Poor self-care (choice A) may contribute to gingival issues, but in this case, the patient's gums are affected by a medication side effect. There is no indication in the question of aspirin use (choice B) or hepatotoxicity (choice D) causing the gum issues. Therefore, the most likely explanation is the adverse effect of phenytoin.
A patient diagnosed with Heart Failure would like the nurse to explain what the diagnosis means. How will the nurse explain heart failure?
- A. The heart muscle cannot pump effectively, causing a backup of blood.
- B. Increased protein leads to reduced oncotic pressure and inability to pull the fluid into the system.
- C. The hydrostatic pressure pushing fluids out of the capillary is lower than the oncotic pressure.
- D. The decrease in venous pressure from the backup of blood increases hydrostatic pressure.
Correct Answer: A
Rationale: The correct answer is A: The heart muscle cannot pump effectively, causing a backup of blood. This is the most accurate explanation of heart failure. In heart failure, the heart is unable to pump blood efficiently, leading to a backup of blood in the circulatory system. This can result in symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation for why the other choices are incorrect:
B: Increased protein leading to reduced oncotic pressure is not a direct cause of heart failure.
C: This choice describes the forces involved in fluid movement, not the primary mechanism of heart failure.
D: Heart failure causes a backup of blood, which in turn increases venous pressure, not the other way around.
In summary, choice A is correct as it directly addresses the primary issue of heart failure, while the other choices focus on different physiological processes not directly related to heart failure.
The nurse teaches the patient receiving propranolol (Inderal) at home for management of ventricular arrhythmias to monitor what parameter?
- A. Weekly pulse.
- B. Daily fluid intake.
- C. Daily blood pressure.
- D. Weekly weight.
Correct Answer: C
Rationale: The correct answer is C: Daily blood pressure. Monitoring daily blood pressure is crucial for a patient taking propranolol for ventricular arrhythmias as it helps assess the effectiveness of the medication in controlling the arrhythmias and ensuring the patient's safety. Changes in blood pressure can indicate potential side effects or worsening of the condition. Monitoring pulse alone (choice A) may not provide a comprehensive picture of the cardiac status. Daily fluid intake (choice B) and weekly weight (choice D) are not specific parameters for monitoring the effects of propranolol on ventricular arrhythmias.
A 6-year-old was complaining of elbow pain. The nurse will advise the patient to give which pain medication?
- A. Aleve.
- B. Motrin.
- C. Acetaminophen (Tylenol).
- D. Aspirin (Ecotin).
Correct Answer: C
Rationale: The correct answer is C, Acetaminophen (Tylenol). Acetaminophen is the safest pain medication for children due to its low risk of side effects like gastrointestinal irritation or bleeding, which can be more common with Aleve (A), Motrin (B), and Aspirin (D). Aspirin specifically is contraindicated in children due to the risk of Reye's syndrome. Acetaminophen is also preferred because it has antipyretic properties, making it effective for reducing fever in addition to pain relief. Ultimately, Acetaminophen is the best choice for a 6-year-old experiencing elbow pain due to its safety profile and effectiveness in managing pain and fever.
A geriatric patient received a narcotic analgesic before leaving the post-anesthesia care unit to return to the regular unit. What is the priority nursing action for the nurse receiving the patient on the regular unit?
- A. Administer a non-steroidal anti-inflammatory drug.
- B. Put side rails up and place bed in the lowest position.
- C. Encourage fluids.
- D. Create a restful dark environment.
Correct Answer: B
Rationale: The correct answer is B: Put side rails up and place bed in the lowest position. This is the priority nursing action as the geriatric patient who received a narcotic analgesic may experience drowsiness or confusion, increasing the risk of falls. By putting up the side rails and lowering the bed, the nurse is ensuring the patient's safety and preventing falls. Administering a non-steroidal anti-inflammatory drug (choice A) is not the priority as the patient's safety should be addressed first. Encouraging fluids (choice C) and creating a restful dark environment (choice D) are important but not as crucial as ensuring the patient's immediate safety.