Nokea
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
Correct Answer: A
Rationale: Decreased breath sounds in the right lower lobe may indicate aspiration or pneumonia, a serious complication requiring immediate intervention to ensure airway patency and prevent further respiratory compromise.
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The doctor has ordered Nitrostat (nitroglycerine) sublingually for a client with angina. The client should be ordered to replenish his supply every:
- A. 6 months
- B. 3 months
- C. 12 months
- D. 18 months
Correct Answer: A
Rationale: Nitroglycerin loses potency after 6 months, requiring replacement to ensure efficacy for angina relief.
Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy?
- A. Take at bedtime.
- B. Take the medication with juice.
- C. Report changes in appetite.
- D. Avoid the sunshine while taking the medication.
Correct Answer: B
Rationale: Lugol's solution (iodine) should be taken with juice to mask its taste and reduce gastric irritation. Taking it at bedtime , reporting appetite changes , or avoiding sunshine are not specific to this medication.
The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?
- A. An appropriate form must be signed, verifying refusal
- B. Complications, including death, could result
- C. The client will be billed for the equipment regardless
- D. The surgeon will be informed of the refusal
Correct Answer: B
Rationale: SCDs prevent deep vein thrombosis (DVT) post-surgery, a potentially fatal complication. Communicating the risk of complications, including death (B), is critical to emphasize the importance of compliance. Signing a refusal form (A), billing (C), or informing the surgeon (D) are secondary to ensuring the client understands the serious risks.
Laboratory results
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 30%
(0.30)
Activated PTT
Baseline: 30–40 sec 110 sec
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 80,000/mm3
(80 x 109/L)
PT
11–12.5 sec 11 sec
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Activated PTT(62%)
- B. Hemotocrit(5%)
- C. Platelets(23%)
- D. PT(8%)
Correct Answer: A
Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial
thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40
seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side
effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina
bleeds (Option 1).
(Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic
anemia, a hematocrit of 30% (0.30) may be an expected finding.
(Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver
cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs
with a platelet count >50,000 mm* (50 x 10%/L).
(Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be
concerning.
The nurse is teaching the client regarding bladder retraining. The ability to remain continent depends on the:
- A. Sympathetic nervous system
- B. Parasympathetic nervous system
- C. Central nervous system
- D. Lower motor neurons
Correct Answer: C
Rationale: The central nervous system coordinates bladder control, integrating sensory input and voluntary control for continence. Other systems play secondary roles.