Nokea
The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering?
- A. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9.
- B. Multiple Choice insulin to a client with a blood glucose level of 218 mg/dL.
- C. Hang the heparin bag on a client with a PT/PTT of 12.9/98.
- D. A calcium channel blocker to the client with a BP of 112/82.
Correct Answer: C
Rationale: PTT 98 (C) is supratherapeutic for heparin, risking bleeding, so question administration. INR 1.9 (A) is subtherapeutic, insulin (B) is appropriate, and CCB (D) is reasonable.
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A patient is ordered at 1400 to take Theophylline. You're assessing the patient's morning lab results and note that the Theophylline level drawn this morning reads: $15 \mathrm{mcg} / \mathrm{mL}$. You're next nursing action is to?
- A. Administer the dose at 1400 as ordered
- B. Notify the physician for further orders
- C. Hold the 1400 dose
- D. Collect another blood sample to confirm the level
Correct Answer: A
Rationale: A Theophylline level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the dose should be administered as ordered . No further action is needed.
Which is the best response from the nurse?
- A. Tell me more about how you are feeling.
- B. There are lots of things you can still do.
- C. You are just having a bad day today.
- D. What makes you say that?
Correct Answer: A
Rationale: Encouraging the client to express feelings fosters therapeutic communication and helps address emotional concerns related to COPD.
What is the best way to determine whether a client with a tracheostomy is becoming hypoxemic during suctioning?
- A. Monitoring level of consciousness
- B. Assessing skin color and temperature
- C. Auscultating the respiratory rate
- D. Counting the respiratory rate
Correct Answer: C
Rationale: Auscultating the respiratory rate detects changes in breathing patterns, indicating potential hypoxemia during suctioning.
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?
- A. Gather the needed supplies for the procedure.
- B. Obtain a signed informed consent form.
- C. Assist the client into a side-lying position.
- D. Discuss the procedure with the client.
Correct Answer: B
Rationale: Informed consent (B) is required before invasive procedures, a priority. Gathering supplies (A), positioning (C), and discussion (D) follow.
A patient is newly diagnosed with COPD due to chronic bronchitis. You're providing education to the patient about this disease process. Which statement by the patient indicates they understood your teaching about this condition?
- A. If I stop smoking, it will cure my condition.'
- B. Complications from this condition can lead to pulmonary hypertension and right-sided heart failure.'
- C. I'm at risk for low levels of red blood cells due to hypoxia and may require blood transfusions during acute illnesses.'
- D. My respiratory system is stimulated to breathe due to high carbon dioxide levels rather than low oxygen levels.'
Correct Answer: B
Rationale: Chronic bronchitis can lead to pulmonary hypertension and right-sided heart failure due to chronic hypoxemia. Smoking cessation slows progression but doesn't cure, low RBCs are not typical, and CO2 drive applies to severe cases.