Nokea
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve
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A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
A client with internal radiation.
Which of the following actions, if taken by the nurse, is MOST important?
- A. Restrict visitors who may have an upper respiratory infection.
- B. Assign only male caregivers to the client.
- C. Plan nursing activities to decrease nurse exposure.
- D. Wear a lead-lined apron whenever delivering client care.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
The nurse is teaching a client about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid contact sports while taking this medication.
- B. I will check with my doctor before taking any new medications.
- C. I will increase my intake of green leafy vegetables.
- D. I will report any unusual bleeding to my doctor.
Correct Answer: C
Rationale: green leafy vegetables are high in vitamin K, which can decrease the effectiveness of warfarin