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The nurse is preparing to administer heparin to a client with a deep vein thrombosis. Which of the following laboratory values should the nurse check before administering the dose?
- A. Prothrombin time (PT).
- B. Activated partial thromboplastin time (aPTT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: B
Rationale: heparin’s therapeutic effect is monitored by aPTT, which should be 1.5–2 times the control value
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The nurse is reviewing a client's PRN pain medications. There is an order for acetaminophen 1,000 mg PO q4 hours as needed for pain. How should the nurse proceed?
- A. call the health care provider to clarify the order
- B. administer the medication as ordered if needed for pain
- C. give other PRN medications for pain and ignore the order
- D. avoid giving pain medication every 4 hours and give it every 6 hours
Correct Answer: B
Rationale: Acetaminophen 1,000 mg q4 hours PRN is within safe dosing (max 4,000 mg/day), so it can be administered as ordered.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.
While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
- A. Stop the medication from infusing
- B. Flush the IV catheter with normal saline
- C. Apply a tourniquet and call the doctor
- D. Continue the IV and assess the site for edema
Correct Answer: A
Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.
The charge nurse is making assignments for the day shift. One of the nurses is 5 months pregnant. Which of the following clients is the most appropriate assignment for this expectant nurse?
- A. a client with shingles
- B. a client with measles
- C. a client with pneumonia
- D. a client with Clostridium difficile
Correct Answer: C
Rationale: Pneumonia is less likely to pose a risk to a pregnant nurse compared to shingles, measles (both vaccine-preventable and highly contagious), or C. difficile (requiring strict contact precautions).
A pediatric nurse volunteers at a health screening fair. The nurse examines a patient. Which of the following findings may be indicative of type 1 diabetes and require further investigation?
- A. stomach bloating, swollen lymph nodes, increased thirst
- B. sudden weight loss, blurry vision, muscle weakness
- C. sudden weight gain, ringing in the ears, difficulty sleeping
- D. feeling hungry all of the time, increased thirst, waking up at night to urinate
Correct Answer: D
Rationale: Type 1 diabetes presents with polyphagia, polydipsia, and polyuria (e.g., waking to urinate). Weight loss (B) is also common, but D is the most specific.