Nokea
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?
- A. The client's partial thromboplastin time (PTT) is 38.
- B. The client's international normalized ratio (INR) is 5.
- C. The client's prothrombin time (PT) is 22.
- D. The client's erythrocyte sedimentation rate (ESR) is 10.
Correct Answer: B
Rationale: An INR of 5 (B) is above the therapeutic range (2–3 for pulmonary embolus), indicating excessive anticoagulation and bleeding risk, so warfarin should be questioned. PTT (A) is for heparin, not warfarin. PT (C) alone is not standardized. ESR (D) is irrelevant to anticoagulation.
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Because of this client's impaired speech, which nursing action facilitates communication?
- A. Discourage the client's attempts at communication.
- B. Inform the client to speak slowly when talking.
- C. Listen attentively to the client's vocalizations.
- D. Provide the client with paper and pencil.
Correct Answer: D
Rationale: Providing paper and pencil allows the client with impaired speech post-laryngectomy to communicate effectively through writing.
Before recommending the use of a nonprescription decongestant to a client with a cold, which aspect of the medical history should be assessed? Select all that apply.
- A. Arthritis
- B. Asthma
- C. Hypertension
- D. Diabetes
- E. Glaucoma
- F. Arrhythmias
Correct Answer: C, E, F
Rationale: Decongestants can exacerbate hypertension, glaucoma, and arrhythmias due to their vasoconstrictive effects. Asthma is also a concern as decongestants may worsen respiratory symptoms in some cases.
The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- A. The UAP keeps the chest tube below chest level.
- B. The UAP has the chest tube attached to suction.
- C. The UAP allowed the client out of the bed.
- D. The UAP uses a bedside commode for the client.
Correct Answer: B
Rationale: Suction during ambulation (B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (A), ambulation (C), and commode (D) are appropriate.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.