Nokea
The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
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A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. Bleeding time
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is used to monitor the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the PTT results. Monitoring PTT helps to ensure that the patient's blood is within the therapeutic range for anticoagulation.
A: Prothrombin time (PT) is used to monitor warfarin therapy, which affects the extrinsic pathway of the coagulation cascade.
C: Bleeding time is not typically used to monitor heparin therapy effectiveness.
D: Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not directly reflect the effectiveness of heparin therapy in preventing or treating DVT.
Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a medical emergency that can lead to tissue damage and loss of limb function. Immediate intervention is crucial to prevent further complications. Finger paresthesias related to carpal tunnel syndrome (A) are not life-threatening and can be managed conservatively. Morton's neuroma (C) and plantar fasciitis (D) are painful conditions, but they do not pose an immediate threat to the client's health or limb function.
A client with cirrhosis is at risk for bleeding. Which laboratory test is most important to monitor?
- A. Blood glucose
- B. Serum creatinine
- C. Prothrombin time (PT)
- D. Electrolytes
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). In cirrhosis, the liver's ability to produce clotting factors is impaired, leading to a higher risk of bleeding. Monitoring PT helps assess the liver's synthetic function and the blood's ability to clot. Abnormal PT values indicate a higher bleeding risk and guide interventions like vitamin K or blood products. Blood glucose (A), serum creatinine (B), and electrolytes (D) do not directly reflect the liver's synthetic function or clotting status in cirrhosis, making them less relevant for monitoring bleeding risk.
A client with a new diagnosis of diabetes mellitus is learning to self-administer insulin. Which instruction should the nurse include?
- A. Store the insulin in the freezer.
- B. Administer the insulin at the same site each time.
- C. Rotate injection sites within the same region.
- D. Shake the vial vigorously before drawing up the insulin.
Correct Answer: C
Rationale: The correct answer is C: Rotate injection sites within the same region. This is important to prevent lipohypertrophy and ensure proper insulin absorption. Administering insulin at the same site each time (B) can lead to tissue damage. Storing insulin in the freezer (A) can alter its effectiveness. Shaking the vial vigorously (D) can cause air bubbles and affect insulin dosage accuracy. Rotation of injection sites within the same region is crucial for consistent absorption and preventing complications.
A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?
- A. Fruity breath odor.
- B. Blood glucose of 450 mg/dL.
- C. Deep, rapid respirations.
- D. Serum potassium of 5.2 mEq/L.
Correct Answer: C
Rationale: Step-by-step rationale:
1. Deep, rapid respirations in DKA indicate Kussmaul respirations, a compensatory mechanism for metabolic acidosis.
2. Immediate intervention is needed to prevent respiratory failure and further acidosis.
3. Administering IV fluids and insulin can help correct acidosis and stabilize breathing.
4. Fruity breath odor (A) and high blood glucose (B) are common in DKA but do not require immediate intervention.
5. Serum potassium of 5.2 mEq/L (D) is slightly elevated but not as urgent as addressing respiratory distress.