Nokea
Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
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The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?
- A. 830
- B. 1100
- C. 1330
- D. 1500
Correct Answer: B
Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?
- A. Check for a history of bipolar disease
- B. Determine if restraints can now be removed
- C. Monitor for ECG changes
- D. Obtain blood for the current blood alcohol level
Correct Answer: B
Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (B) is the priority to minimize harm and promote safety. Bipolar history (A), ECG changes (C), and blood alcohol level (D) are important but less urgent.
The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus
- A. 12 cm above the umbilicus
- B. at the level of the umbilicus
- C. just below the xiphoid process
- D. just above the symphysis pubis
Correct Answer: D
Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.
A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.