Nokea
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
- A. Assess the client for abnormal bleeding.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Administer the medication as ordered.
- D. Notify the HCP to obtain an order to increase the dose.
Correct Answer: C
Rationale: INR 2.8 (C) is therapeutic for PE (2–3), so administer warfarin. Bleeding assessment (A) is routine, vitamin K (B) reverses overdose, and increasing dose (D) is unnecessary.
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What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.
Which question is essential for the nurse to ask before administering the influenza vaccine?
- A. Have you had influenza in the last year?
- B. Did you receive pneumonia vaccine last year?
- C. Are you allergic to eggs or egg products?
- D. Do you have a history of respiratory disease?
Correct Answer: C
Rationale: Influenza vaccines are often produced using eggs, so an egg allergy must be assessed to prevent allergic reactions.
You're assisting your patient who has asthma to bed. The patient is experiencing a frequent cough and chest tightness. You auscultate the patient's lung fields and note expiratory wheezes. The patient's peak flow rate is 78% less than their best peak flow reading. Which medication will provide the patient with the fastest relief from these signs and symptoms of an asthma attack?
- A. Theophylline
- B. Tiotropium
- C. Albuterol
- D. Cromolyn
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation, making it the fastest-acting medication for acute asthma symptoms.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.
The term 'blue bloaters' is used to describe patients with?
- A. Pulmonary hypertension
- B. Left-sided heart failure
- C. Chronic Bronchitis
- D. Emphysema
Correct Answer: C
Rationale: Blue bloaters' describes chronic bronchitis patients, who present with cyanosis ('blue') and edema ('bloating') due to hypoxemia and right heart failure. Emphysema patients are often called 'pink puffers.'