Nokea
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
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The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
- A. Noisy respirations.
- B. Pupillary constriction.
- C. Halitosis.
- D. Moist skin.
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
- A. Hearing problems.
- B. Speech defect.
- C. Chronic sinus infections.
- D. Tonsillitis.
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
- A. For clients with an inevitable death within weeks to months
- B. For all clients with AIDS at any stage
- C. Only for clients with cancer
- D. When the client is ready to discuss his prognosis
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
The nurse is caring for a client with a diagnosis of peptic ulcer disease. When monitoring the client for possible gastrointestinal perforation, the nurse identifies the importance of what assessment data?
- A. Slow, strong pulses
- B. Increase in bowel sounds
- C. Positive guaiac stool tests
- D. Sudden, severe abdominal pain
Correct Answer: D
Rationale: Sudden, severe abdominal pain is a sign of perforation. When perforation occurs, the pulse will more likely be weak and rapid. The nurse may be unable to hear bowel sounds at all. Positive guaiac stool results indicate the presence of bleeding but are not necessarily indicative of perforation.
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.