Nokea
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
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A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Hemoglobin
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
Which statement about environmental safety is accurate?
- A. The nurse should advise clients in a smoke filled room to open the windows.
- B. The first thing that the nurse should do when using a fire extinguisher to put out a small fire is to aim the fire extinguisher at the base of the fire.
- C. Rapidly lift and move a client away from the source of the fire when their slippers are on fire.
- D. The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher.
Correct Answer: D
Rationale: Advising clients to have an ABC fire extinguisher is accurate, as it is versatile for multiple fire types. Opening windows may worsen a fire, aiming the extinguisher follows pulling the pin, and rapid lifting risks injury.
The nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statement by the client indicates an understanding of the medication?
- A. I should put ice on my lips if they swell.
- B. I need to take the medication 2 hours after I eat.
- C. I need to drink at least 8 glasses of liquids every day.
- D. I can use an antihistamine lotion if I get a rash that is itchy.
Correct Answer: C
Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the primary health care provider because this may indicate hypersensitivity. Allopurinol is to be given with or immediately after meals or milk.
Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
- A. Injecting the medication via an infusion device
- B. Massaging the injection site after administration
- C. Injecting the medication 1 inch from the umbilicus
- D. Avoiding aspiration before administration of the medication
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.