Nokea
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
- A. Awake the client
- B. Check the armband for client identification number and compare with the order
- C. Label the sample vial in front of the client
- D. Verify the room number with the room assignment
- E. Ask the client to state his/her name
Correct Answer: B,C,E
Rationale: Rationales: B) Checking the armband ensures correct client identification, critical for safety. C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity. A) Awakening the client is unnecessary if asleep, as the draw can be done gently. D) Room number is unreliable for identification.
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The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
- A. Decreased mental status.
- B. Elevated blood pressure.
- C. Decreased urine output.
- D. Labored respirations.
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (A) due to ammonia buildup. Elevated blood pressure (B), decreased urine output (C), and labored respirations (D) are not primary indicators.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply.
- A. Deltoid.
- B. Greater femur trochanter.
- C. Acromion muscle.
- D. Ventrogluteal.
- E. Upper back.
- F. Dorsogluteal.
Correct Answer: A,D,F
Rationale: Vitamin B12 is administered intramuscularly, and appropriate sites include the deltoid, ventrogluteal, and dorsogluteal muscles, as these provide adequate muscle mass for absorption. The greater femur trochanter and acromion muscle are not standard injection sites, and the upper back is not suitable for intramuscular injections.
Which dietary modification is appropriate for a client with calcium oxalate stones?
- A. Increase dairy intake.
- B. Limit spinach consumption.
- C. Reduce fluid intake.
- D. Eat more red meat.
Correct Answer: B
Rationale: Spinach is high in oxalates, which contribute to calcium oxalate stone formation.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
- A. Remove the peripheral vascular access device
- B. Obtain an order for phentolamine
- C. Notify the physician
- D. Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
- E. Disconnect administration set
Correct Answer: A,C,F
Rationale: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.