Nokea
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is crucial as it assesses the client's capability and involvement in the process, promoting independence and preventing complications. Choice B is incorrect as assistive devices may be necessary for safety. Choice C is incorrect as raising side rails can limit access and may not be needed. Choice D is incorrect as discussing preferences is important but not directly related to repositioning.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
Which of the following findings indicates that the child may be experiencing hemorrhage?
- A. Increased drowsiness
- B. Elevated pain level
- C. Diminished breath sounds
- D. Frequent swallowing
Correct Answer: D
Rationale: Frequent swallowing can indicate bleeding in the throat post-tonsillectomy.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client,If you don't eat I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?"
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault refers to the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client constitutes a threat of physical harm, which falls under the definition of assault. The nurse should intervene to prevent any potential harm to the client. The other choices are incorrect because: A: Battery involves actual harmful or offensive contact, which has not occurred in this situation. C: Negligence refers to a failure to provide reasonable care, not a threat of harm. D: Malpractice involves professional negligence or misconduct, which is not demonstrated in this scenario.