Nokea
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer vitamin K as a reversal agent.
- D. Recheck the INR in 4 hours.
Correct Answer: B
Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified
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The nurse is caring for a 28-year-old female with a long history of heroin addiction. The client tells the nurse that she started off using a small amount recreationally, but as time went on, she needed more and more heroin to feel a high. The nurse recognizes this as
- A. addiction.
- B. dependence.
- C. tolerance.
- D. withdrawal.
Correct Answer: C
Rationale: Tolerance is the need for increasing doses to achieve the same effect, as described in the client’s heroin use.
The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.
- A. decreased ALT levels
- B. increased AST levels
- C. elevated ammonia levels
- D. low serum albumin levels
- E. shortened prothrombin time
Correct Answer: B, C, D
Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.
The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- A. Colorful crib mobile
- B. Hand-held electronic games
- C. Cars in a plastic container
- D. 30-piece jigsaw puzzle
Correct Answer: A
Rationale: A colorful crib mobile is age-appropriate and safe for a 6-month-old on bed rest, providing visual stimulation.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.