Nokea
The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Double the dose to achieve therapeutic range.
- D. Administer half the dose.
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
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When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:
- A. 30 minutes
- B. 1-4 hours
- C. 12-24 hours
- D. 24-72 hours
Correct Answer: D
Rationale: Synthetic cast materials harden in 3-15 minutes. Weight bearing is permitted in 15-30 minutes. Drying time for plaster of Paris is about 24-72 hours. (B, C) Plaster of Paris cast materials are heavier than synthetic materials and require a drying time of 24-72 hours. Synthetic materials dry within 30 minutes. Plaster of Paris cast materials are heavier than synthetic materials and require a longer period to set and dry. Even though setting time (hardening) is only 3-15 minutes, the drying time for plaster of Paris is 24-72 hours. This depends on the size and thickness of the cast, exposure to air, and humidity in the air.
A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.
Correct Answer: 21 pounds
Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
- A. Reinforce the dressing.
- B. Continue to monitor the dressing.
- C. Notify the physician.
- D. Note the time and amount of blood.
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.
The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Hyperthermia
Correct Answer: A
Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- B. Child lying flat
- C. Head turned to side
- D. Frequent visitation for stimulation
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.