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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 professional is reinforcing teaching for a client with peripheral artery disease (PAD). Which statement by the client indicates a need for further teaching?
- A. I will keep my legs elevated on pillows while resting.
- B. I will avoid crossing my legs when sitting.
- C. I will wear loose-fitting, comfortable shoes.
- D. I will avoid exposure to cold temperatures.
Correct Answer: A
Rationale: The correct answer is A. Elevating the legs can decrease blood flow in clients with PAD, worsening symptoms. Therefore, advising the client to keep the legs elevated on pillows while resting is incorrect and can exacerbate the condition. Choice B is correct as avoiding crossing legs helps prevent circulation restriction. Choice C is correct as wearing loose-fitting shoes promotes circulation. Choice D is correct as avoiding exposure to cold temperatures helps prevent vasoconstriction, which can worsen PAD symptoms.
When reinforcing dietary instructions to a client with coronary artery disease prescribed a low-fat, low-cholesterol diet, which food item should the nurse advise the client to choose?
- A. Whole milk
- B. Grilled salmon
- C. Fried chicken
- D. Bacon and eggs
Correct Answer: B
Rationale: Grilled salmon is the correct choice for a client with coronary artery disease on a low-fat, low-cholesterol diet because it is low in saturated fat and high in omega-3 fatty acids, which are beneficial for heart health. Whole milk, fried chicken, and bacon and eggs are higher in saturated fats and cholesterol, making them less suitable choices for this client. Whole milk is high in saturated fat, while fried chicken and bacon and eggs are sources of both saturated fat and cholesterol, which can negatively impact heart health in clients with coronary artery disease.
The healthcare provider is preparing to administer a calcium channel blocker to a client with hypertension. What parameter should be checked before administering the medication?
- A. Apical pulse
- B. Serum calcium level
- C. Blood pressure
- D. Respiratory rate
Correct Answer: C
Rationale: Before administering a calcium channel blocker to a client with hypertension, the healthcare provider should check the client's blood pressure. Calcium channel blockers are used to lower blood pressure, making it essential to assess the current blood pressure to ensure it is within the appropriate range for administration. Checking the apical pulse (choice A) is not the priority before administering a calcium channel blocker, as the focus should be on blood pressure. Serum calcium level (choice B) is not directly related to the administration of calcium channel blockers for hypertension. Respiratory rate (choice D) is not the primary parameter to check before administering a calcium channel blocker in this scenario.
The nurse is caring for a client with hypertension who is prescribed a thiazide diuretic. The nurse should check which parameter before administering the medication?
- A. Serum potassium level
- B. Blood pressure
- C. Heart rate
- D. Serum sodium level
Correct Answer: B
Rationale: Before administering a thiazide diuretic to a client with hypertension, the nurse should check the blood pressure. Thiazide diuretics are prescribed to lower blood pressure, so assessing the client's blood pressure prior to administration helps to monitor the effectiveness of the medication and to ensure the client's safety. Checking the serum potassium level (Choice A), heart rate (Choice C), or serum sodium level (Choice D) are also important parameters in the care of a client on a thiazide diuretic, but the priority assessment before administering the medication is the blood pressure to evaluate the drug's effectiveness in managing hypertension.