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The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.
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A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?
- A. Increased anxiety and nervousness have been reported by those taking feverfew.
- B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew.
- C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew.
- D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: B
Rationale: Feverfew can cause allergic reactions in individuals allergic to chamomile, ragweed, or yarrow, making this critical to prevent serious reactions. Anxiety, GI effects, or NSAID interactions are less urgent.
The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
- A. Apply a telemetry monitor before administering the dose.
- B. Assess for orthostatic hypotension before administering the dose.
- C. Administer the dose and monitor the client's blood pressure regularly.
- D. Withhold the scheduled dose and notify the healthcare provider.
Correct Answer: D
Rationale: A heart rate of 48 beats/minute indicates bradycardia, a concern with labetalol (a beta-blocker). Withholding the dose and notifying the provider is appropriate to prevent worsening bradycardia.
A female client with osteoporosis has been taking a weekly dose of oral risedronate for several weeks. The client calls the clinic nurse to report increasing 'heartburn.' How should the nurse respond?
- A. Ask the client to describe how she takes the medication.
- B. Remind the client to take the medication with plenty of water.
- C. Advise the client to go to the nearest emergency department.
- D. Suggest use of an antacid two hours after the medication.
Correct Answer: A
Rationale: Risedronate can cause esophageal irritation if not taken properly. Assessing the client’s administration technique (e.g., with water, staying upright) identifies potential causes of heartburn, guiding further intervention.
An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)
- A. Bowel sounds.
- B. Daily weight.
- C. Heart sounds.
- D. Blood pressure.
- E. Range of motion.
Correct Answer: B,C,D
Rationale: B: Daily weight monitors fluid retention (furosemide effectiveness). C: Heart sounds assess heart failure control (atenolol, enalapril). D: Blood pressure evaluates hypertension management (atenolol, enalapril). Bowel sounds and range of motion are unrelated to these medications’ effects.
Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.
- A. Dizziness while sitting up: Non-therapeutic side effect
- B. Blood glucose 218mg/dl: Unrelated finding
- C. Mouth dryness: Non-therapeutic side effect
- D. Blood pressure 162/111mmHg: Therapeutic result
- E. Heart rate 99: Non-therapeutic side effect
- F. Pain of 1 out of 10: Unrelated finding
- G. Urine output 600ml: Unrelated finding
Correct Answer:
Rationale: A: Dizziness is a minoxidil side effect (hypotension). B: High glucose relates to diabetes. C: Dry mouth is a possible side effect. D: Lowered blood pressure is therapeutic. E: Tachycardia is a side effect. F: Pain reduction relates to ibuprofen. G: Urine output is unrelated.