Nokea
The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?
- A. Obtain a 12-lead ECG
- B. Monitor the client's blood pressure
- C. Notify the healthcare provider
- D. Administer a second dose of nitroglycerin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client with a diagnosis of heart failure is prescribed spironolactone (Aldactone). Which laboratory value should be monitored closely by the nurse?
- A. Serum calcium
- B. Serum potassium
- C. Serum sodium
- D. Serum glucose
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client receiving anticoagulant therapy. Which instruction should the nurse reinforce with the client to prevent bleeding complications?
- A. Use a soft-bristle toothbrush and electric razor.
- B. Increase your intake of vitamin K-rich foods.
- C. Take aspirin if you have a headache.
- D. Avoid using ice packs for injuries.
Correct Answer: A
Rationale: The correct instruction to prevent bleeding complications in a client on anticoagulant therapy is to use a soft-bristle toothbrush and electric razor. These implements help reduce the risk of bleeding by being gentle on the skin and reducing the chances of cuts or abrasions that could lead to bleeding in individuals on anticoagulants.
A client is receiving intravenous heparin therapy for the treatment of deep vein thrombosis (DVT). Which laboratory test result should the LPN/LVN monitor to ensure the client is receiving a therapeutic dose?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct laboratory test result that the LPN/LVN should monitor to ensure the client is receiving a therapeutic dose of heparin therapy is the activated partial thromboplastin time (aPTT). The aPTT test is specifically used to monitor heparin therapy, ensuring that the dose administered is within the therapeutic range. Monitoring aPTT helps to prevent complications such as bleeding or clot formation by maintaining the appropriate anticoagulant effect of heparin.
The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?
- A. Avoid consuming foods high in vitamin K while taking this medication.
- B. Administer the injection in the same site each time for consistency.
- C. Report any unusual bleeding or bruising to your healthcare provider.
- D. Do not take aspirin if you experience any mild pain or discomfort.
Correct Answer: C
Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is important because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin, and should be promptly addressed by a healthcare provider to prevent complications.
A client with heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?
- A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute
- B. Increase your fluid intake to at least 3 liters per day
- C. Report any weight loss of more than 2 pounds in a week
- D. Take the medication with meals to avoid gastrointestinal upset
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.