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The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
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A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
- A. Which symptom should the nurse expect initially in a client with a subdural hematoma and cerebral edema?
- B. Unequal and dilated pupils.
- C. Decerebrate posturing.
- D. Grand mal seizures.
- E. Decreased level of consciousness.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
- A. Ice cream
- B. Beef broth
- C. Apple juice
- D. Iced tea
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.
The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.
The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans would be a priority to meet the needs of this father?
- A. Encourage the father to call his wife after work.
- B. Instruct the father about visiting policy and suggest AM visitation.
- C. Adjust visiting hours to meet the new parents' needs.
- D. Present a change of visiting hours to the appropriate hospital committee.
Correct Answer: C
Rationale: Adjusting visiting hours accommodates the father’s evening shift, enabling bonding with his newborn, a priority for family-centered care. Options A and B are less flexible, and option D is a long-term solution, not immediate.