Nokea
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. Hemoglobin level
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. With heparin being an anticoagulant, monitoring PTT helps ensure the client is within the therapeutic range to prevent clot formation. A - Platelet count assesses risk of bleeding, not heparin effectiveness. B - Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. D - Hemoglobin level monitors for anemia, not heparin effectiveness.
You may also like to solve these questions
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress.
A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath.
B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath.
C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
- A. Monitor serum calcium levels
- B. Obtain a baseline electrocardiogram
- C. Implement seizure precautions
- D. Encourage a low-protein diet
Correct Answer: C
Rationale: The correct answer is C. Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push effectively to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct Answer: D
Rationale: The correct answer is D. The nurse-manager should ask the nurses to meet to identify ways of working together. This is the best action because it promotes open communication, collaboration, and conflict resolution between the two nurses. By facilitating a discussion between them, the nurse-manager can help address the underlying issues, clarify misunderstandings, and find common ground for effective teamwork. This approach encourages mutual understanding and fosters a positive working relationship.
A: Having both nurses meet separately with the staff mental health consultant does not directly address the conflict between them.
B: While listening actively and offering suggestions is important, involving both nurses in the discussion is crucial for resolving the conflict.
C: Asking the senior nurse to examine mentoring strategies does not involve the new graduate in the conversation and may not address the overall issue.
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
- A. Notify the healthcare provider of the laboratory results
- B. Decrease the rate of the IV infusion
- C. Stop the infusion
- D. Administer sodium polystyrene sulfonate (Kayexalate)
Correct Answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion (Choice C). Oliguria and a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications.
Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.