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The nurse is assisting with the care of a client who is on a continuous heparin infusion for deep vein thrombosis (DVT). Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: To evaluate the effectiveness of heparin therapy in a client with DVT, the nurse should monitor the activated partial thromboplastin time (aPTT). The aPTT test helps ensure that the dose of heparin is within the therapeutic range, which is essential for preventing clot formation or excessive bleeding. Monitoring aPTT is crucial in managing patients on heparin therapy to maintain the delicate balance between preventing thrombosis and avoiding hemorrhage. Prothrombin time (PT) and International normalized ratio (INR) are more indicative of warfarin therapy effectiveness, not heparin. Platelet count assesses platelet levels and function, not the effectiveness of heparin therapy for DVT.
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The nurse is preparing to administer an intravenous dose of furosemide (Lasix) to a client with heart failure. The nurse should monitor for which potential side effect?
- A. Hypertension
- B. Hyperkalemia
- C. Hypokalemia
- D. Hypoglycemia
Correct Answer: C
Rationale: Furosemide is a loop diuretic that works by promoting the excretion of water and electrolytes, including potassium. This loss of potassium can lead to hypokalemia, which can be a potential side effect of furosemide administration. Hypokalemia can result in cardiac dysrhythmias and other complications, especially in clients with heart failure who may already have compromised cardiac function. Therefore, monitoring for signs of hypokalemia, such as muscle weakness, cardiac irregularities, and fatigue, is essential when administering furosemide. Choice A, hypertension, is incorrect because furosemide is actually used to treat hypertension by reducing excess fluid in the body. Choice B, hyperkalemia, is incorrect as furosemide causes potassium loss, leading to hypokalemia. Choice D, hypoglycemia, is unrelated to the mechanism of action of furosemide and is not a common side effect associated with its administration.
The healthcare provider is preparing to administer a beta blocker to a client with hypertension. What parameter should be checked before administering the medication?
- A. Serum potassium level
- B. Apical pulse
- C. Oxygen saturation
- D. Pupil reaction to light
Correct Answer: B
Rationale: Before administering a beta blocker, it is crucial to check the apical pulse. Beta blockers have the potential to slow down the heart rate, making it essential to assess the pulse rate to ensure it is within the safe range before giving the medication. Checking the serum potassium level (choice A) is important when administering certain medications, but it is not specifically required before giving a beta blocker. Oxygen saturation (choice C) and pupil reaction to light (choice D) are not directly related to monitoring parameters for beta blocker administration.
The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.
The client with a new prescription for warfarin (Coumadin) is receiving teaching from the LPN/LVN. Which statement by the client indicates an understanding of the medication?
- A. I will avoid eating foods high in vitamin K, like spinach and broccoli.
- B. I will take aspirin instead of acetaminophen for headaches while on this medication.
- C. I can stop taking the medication once my symptoms improve.
- D. I will double my dose if I miss a dose to catch up.
Correct Answer: A
Rationale: Clients prescribed with warfarin (Coumadin) need to maintain a consistent intake of vitamin K and avoid sudden increases in foods rich in vitamin K as it can interfere with the effectiveness of the medication. Choice A, 'I will avoid eating foods high in vitamin K, like spinach and broccoli,' is the correct statement indicating an understanding of the medication. This choice demonstrates knowledge of the importance of consistent vitamin K intake to prevent fluctuations in warfarin's effectiveness. Choices B, C, and D are incorrect. Choice B suggests a substitution that is not advised without consulting a healthcare provider. Choice C is incorrect as stopping warfarin suddenly can lead to serious health risks. Choice D is unsafe and incorrect since doubling the dose is not the correct action if a dose is missed.
A client with chronic heart failure has been prescribed furosemide (Lasix). Which instruction should the nurse reinforce to the client regarding this medication?
- A. Take the medication with food.
- B. Limit foods high in potassium while taking this medication.
- C. Report any muscle cramps or weakness to your healthcare provider.
- D. Expect to urinate more frequently while on this medication.
Correct Answer: C
Rationale: The correct instruction for the nurse to reinforce to the client regarding furosemide (Lasix) is to report any muscle cramps or weakness to the healthcare provider. Muscle cramps or weakness may indicate hypokalemia, a potential side effect of furosemide. Monitoring and reporting these symptoms promptly can help in preventing complications related to electrolyte imbalances. Choice A is incorrect because furosemide should be taken on an empty stomach. Choice B is not directly related to furosemide use; in fact, foods high in potassium may be beneficial for clients taking furosemide to prevent hypokalemia. Choice D is a common expected side effect of furosemide due to its diuretic action but is not as crucial to report as potential signs of electrolyte imbalances.