Nokea
The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?
- A. Prothrombin time
- B. Clot retraction time
- C. Partial thromboplastin time
- D. Bleeding time
Correct Answer: A
Rationale: Prothrombin time (PT/INR) measures the therapeutic level of warfarin, ensuring effective anticoagulation.
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Which task should be assigned to the nursing assistant?
- A. Placing the client in seclusion
- B. Emptying the Foley catheter of the preeclamptic client
- C. Feeding the client with dementia
- D. Ambulating the client with a fractured hip
Correct Answer: C
Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.
A client is hospitalized in a long-term care facility because of Alzheimer disease. The client is incontinent of urine and feces. The nurse has delegated incontinent care to unlicensed assistive personnel (UAP). How frequently should the nurse advise that the UAP check the client for dryness?
- A. Every 2 hours
- B. Every hour
- C. When the client appears restless.
- D. Before meals and at bedtime
Correct Answer: A
Rationale: Checking every 2 hours (A) ensures timely care to prevent skin breakdown in an incontinent client. Hourly checks (B) are excessive, and checking only when restless (C) or before meals (D) is insufficient.
The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within:
- A. 2 weeks
- B. 6 weeks
- C. 8 weeks
- D. 12 weeks
Correct Answer: D
Rationale: With effective treatment, sputum cultures for tuberculosis typically become negative within 2-3 months (approximately 12 weeks), depending on the regimen and adherence.
When preparing a client for admission to the surgical suite, the nurse recognizes that which one of the following items is most important to remove before sending the client to surgery?
- A. Hearing aid
- B. Contact lenses
- C. Wedding ring
- D. Dentures
Correct Answer: B
Rationale: Contact lenses must be removed before surgery to prevent corneal damage or injury under anesthesia, especially if electrocautery is used, which could cause burns if foreign objects are present in the eyes.