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The nurse is caring for a patient receiving warfarin and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which?
- A. Vitamin K Level.
- B. PTT and aPTT.
- C. International normalized ratio (INR).
- D. Platelet level.
Correct Answer: C
Rationale: The correct answer is C: International normalized ratio (INR). When a patient on warfarin presents with bruising and petechiae, it suggests potential over-anticoagulation. INR measures the effectiveness of warfarin therapy by assessing clotting time. An elevated INR indicates a higher risk of bleeding due to excessive anticoagulation. Ordering a Vitamin K level (choice A) is not necessary as the patient is already on warfarin. PTT and aPTT (choice B) are not specific to monitoring warfarin therapy. Platelet level (choice D) is not indicated for assessing warfarin effects.
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The nurse is preparing to administer amoxicillin (Amoxil) to a patient and learns that the patient previously experienced a rash when taking penicillin. Which action will the nurse take?
- A. Administer the amoxicillin and penicillin available.
- B. Contact the provider to discuss using a different antibiotic.
- C. Ask the provider to order an antihistamine.
- D. Request an order for a beta-lactamase resistant drug.
Correct Answer: B
Rationale: The correct action is to contact the provider to discuss using a different antibiotic (Choice B) because the patient has a history of rash with penicillin. Since amoxicillin belongs to the same class of antibiotics as penicillin, there is a high risk of the patient experiencing a similar allergic reaction. By contacting the provider, the nurse can ensure the safety of the patient by exploring alternative antibiotics that are not in the same class as penicillin. This proactive approach prioritizes patient safety and minimizes the risk of an allergic reaction. Administering both amoxicillin and penicillin (Choice A) would be contraindicated due to the patient's history of rash. Asking for an antihistamine (Choice C) alone may not address the underlying issue of cross-reactivity between penicillin and amoxicillin. Requesting a beta-lactamase resistant drug (Choice D) is not necessary in this situation and does not address the patient's known allergy.
What concept is considered when generic drugs are substituted for brand-name drugs?
- A. Half Life.
- B. Critical concentration.
- C. Distribution.
- D. Bioavailability.
Correct Answer: D
Rationale: The correct answer is D: Bioavailability. Bioavailability refers to the extent and rate at which the active ingredient of a drug is absorbed and becomes available at the site of action in the body. When generic drugs are substituted for brand-name drugs, bioavailability is crucial to ensure that the generic drug delivers the same therapeutic effect as the brand-name drug. A higher bioavailability indicates that the generic drug is absorbed efficiently and can produce the desired clinical effect. Half-life (A) is the time required for the concentration of a drug in the body to decrease by half, not directly related to drug substitution. Critical concentration (B) is the minimum concentration of a drug needed to produce a therapeutic effect, not specifically considered in drug substitution. Distribution (C) refers to the process of drug transport within the body, not directly linked to drug substitution.
A nurse is caring for a six-year-old child who had surgery that morning. The child is awake and lying very still in bed. What should the nurse do?
- A. Use an “ouch†scale for pain assessment.
- B. Encourage the child to request pain medication when needed.
- C. Plan to administer pain medication if the child begins to cry.
- D. Ask the child to rate their pain on a scale of 1 to 10.
Correct Answer: A
Rationale: The correct answer is A: Use an "ouch" scale for pain assessment. This approach is appropriate for a six-year-old child as it uses a simple and understandable method to assess pain levels. The child may not verbalize pain or cry, so using a visual scale like an "ouch" scale can help the nurse accurately assess the child's pain level. Encouraging the child to request pain medication (B) assumes the child will always feel comfortable expressing their needs, which may not be the case. Planning to administer pain medication if the child cries (C) may lead to unnecessary medication administration if the child is not in pain. Asking the child to rate their pain on a scale of 1 to 10 (D) may be too complex for a young child to understand and communicate effectively.
The nurse is helping develop a plan of care for a patient that has advanced Alzheimer's disease. The patient will be taking a new medication. Which is a realistic goal for this patient?
- A. Exhibit ability to provide self-care.
- B. Show improved memory for recent events.
- C. Receive appropriate assistance for care needs.
- D. Demonstrate improved cognitive function.
Correct Answer: C
Rationale: The correct answer is C: Receive appropriate assistance for care needs. For a patient with advanced Alzheimer's disease, improving memory or cognitive function is unrealistic due to the progressive nature of the disease. Providing self-care may also be beyond their ability. Setting a goal for the patient to receive appropriate assistance for care needs is realistic and important for maintaining their quality of life and safety. This goal focuses on ensuring the patient's basic needs are met and promoting their overall well-being despite their cognitive decline. It prioritizes practical support and enhances the patient's quality of life.
The nursing instructor asks the student nurse to explain the action of sumatriptan. What is the student's best response?
- A. Vasodilation of peripheral blood vessels.
- B. Depresses pain response in the central nervous system.
- C. Vasoconstrictive on cranial blood vessels.
- D. Binds to acetylcholine receptors to prevent nerve transmission.
Correct Answer: C
Rationale: The correct answer is C: Vasoconstrictive on cranial blood vessels. Sumatriptan is a medication used to treat migraines by constricting blood vessels in the brain, which helps to reduce inflammation and pain associated with migraines. This action helps to alleviate migraine symptoms. Choices A, B, and D are incorrect because sumatriptan does not cause vasodilation, depress pain response in the central nervous system, or bind to acetylcholine receptors. Sumatriptan specifically targets cranial blood vessels to relieve migraine symptoms.