Nokea
The nurse is reviewing the patient's daily PT and INR levels. The PT level is 26 (normal = 9 to 12 seconds). Which of the ff. actions should the nurse take?
- A. Give the next dose of warfarin when it is ordered to be given.
- B. Inform physician before the next dose of warfarin is given. c.Stop the heparin infusion.
- C. Continue monitoring heparin infusion.
Correct Answer: B
Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.
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Why would a Heimlich maneuver be performed on a client?
- A. To increase the absorption of the prescribed medication
- B. To clear the airway if the client cannot speak or breathe after swallowing food
- C. To reduce the potential for injuries as a result of falls
- D. To maintain extremities in proper anatomic position CARING FOR CLIENT WITH HEAD AND SPINAL CORD TRAUMA
Correct Answer: B
Rationale: The Heimlich maneuver, also known as abdominal thrusts, is performed on a client to clear the airway if the client is choking and cannot speak or breathe after swallowing food. The maneuver involves applying upward pressure on the abdomen in an effort to forcefully expel the object blocking the airway. It is a crucial life-saving technique that can prevent the client from suffocating due to an obstructed airway. In cases of choking emergencies, the Heimlich maneuver should be administered promptly to effectively remove the obstruction and restore breathing.
Joel has some internal bleeding. At which of the following sites is the most common for the child with hemophilia to bleed?
- A. Cerebrum
- B. Intestines
- C. Ends of the log bones
Correct Answer: C
Rationale: In children with hemophilia, the most common site for bleeding is at the ends of the long bones, such as the joints (especially the knees, elbows, and ankles). This is due to the joints being more prone to injury and stress during physical activities. As a result, spontaneous bleeding or bleeding following minor trauma can occur at these sites. Internal bleeding in the cerebrum or intestines is less common in children with hemophilia compared to bleeding in the joints.
A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
- A. The patient rates the pain at 3 to 4 on a 0 to 10 scale
- B. The patient has full ROM of the upper extremities
- C. The patient demonstrates correct self-administration of analgesics
- D. The patient is able to ambulate 25 feet without pain
Correct Answer: D
Rationale: The patient being able to ambulate 25 feet without pain is the most appropriate outcome to indicate the success of the plan for impaired mobility related to nerve compression due to a herniated lumbar disk. This outcome directly reflects an improvement in mobility, which is the primary goal when addressing impaired mobility caused by nerve compression. A reduction in pain intensity (choice A) is important but not as specific to mobility impairment. Having full range of motion (choice B) in the upper extremities is not directly related to the issue of lumbar disk herniation. Correct self-administration of analgesics (choice C) is important for pain management but does not directly reflect improvement in mobility.
A 3-year-old attends her grandfather's funeral. Her parents told her he is in heaven with God. Which statement best describes her understanding of spirituality?
- A. The body is here, and the spirit is in heaven.
- B. He is in heaven. Is this heaven?
- C. She will think that because she can see his body, he must still be here.
- D. He won't need his body in heaven.
Correct Answer: C
Rationale: Three-year-olds are literal thinkers; if they see a body, they may assume that the person is still present.
What is a common initial reaction of parents to illness or injury and hospitalization in their child?
- A. Anger
- B. Fear
- C. Depression
- D. Helplessness
Correct Answer: B
Rationale: A common initial reaction of parents to illness or injury and hospitalization in their child is fear. When a parent receives news that their child is unwell or requires hospitalization, it can trigger feelings of fear about the child's well-being, the seriousness of the situation, the treatment process, and the overall outcome. Fear of the unknown, concern for their child's pain and suffering, and worries about the future can all contribute to this initial reaction. It is a natural response for parents to be fearful in such situations as they navigate through the uncertainty and challenges associated with their child's illness or injury.