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The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. D-dimer.
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
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The nurse is preparing a presentation on nutrition to a group of pregnant adolescents. Which of the following would be important for the nurse to include in the teaching plan?
- A. Spinach is an excellent source of calcium in the diet.
- B. Two to four servings of whole-grain products is recommended.
- C. Three or more servings of dairy products meet the calcium requirement.
- D. Vitamin A supplements may be necessary for clients who are vegetarian.
Correct Answer: C
Rationale: Three or more servings of dairy products provide adequate calcium, essential for fetal development and maternal bone health during pregnancy.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which of the following adverse effects?
- A. Tachycardia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Weight loss.
Correct Answer: A
Rationale: Theophylline can cause tachycardia due to its stimulant effects.
The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?
- A. Administer an antacid.
- B. Insert a nasogastric tube.
- C. Prepare for endoscopy.
- D. Administer a proton pump inhibitor.
Correct Answer: B
Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.
The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the figure as having:
- A. Normal posture
- B. Kyphosis
- C. Scoliosis
- D. Lordosis
Correct Answer: C
Rationale: Scoliosis is characterized by a lateral curvature of the spine, which may be observed in a teenager. Kyphosis involves forward curvature, lordosis involves inward lumbar curvature, and normal posture lacks these abnormalities.
The nurse teaches a client taking desmopressin (DDAVP) nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when he makes which of the following comments?
- A. I should check for sores in my nose while taking this medication.'
- B. I should use the same nostril each time I take the medicine.'
- C. I should report nasal congestion.'
- D. I should report any signs of respiratory infection.'
Correct Answer: B
Rationale: Using the same nostril each time can cause irritation or reduced efficacy; alternating nostrils is recommended. The other comments reflect correct understanding of desmopressin use.