Nokea
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
You may also like to solve these questions
Which of the following statement best describe disability?
- A. Temporary loss of function
- B. Permanent loss of function
- C. Absence of disease
- D. A state of well being
Correct Answer: B
Rationale: Disability is permanent loss of function (B), per definition e.g., amputation impact. Temporary (A) is impairment, absence (C) health, well-being (D) opposite. B best defines disability's chronicity, making it correct.
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
The nurse checked if Mr. Gary's pain improved after medication. This is an example of?
- A. Evaluation
- B. Implementation
- C. Assessment
- D. Planning
Correct Answer: A
Rationale: Checking pain improvement is evaluation (A) assessing outcomes, per process. Implementation (B) delivers, assessment (C) gathers, planning (D) sets not outcome-specific. A fits goal review, making it correct.
You are about to write an information on the Kardex. There are 4 available writing instruments to use. Which of the following should you use?
- A. Mongol #2
- B. Permanent Ink
- C. A felt or fountain pen
- D. Pilot Pentel Pen marker
Correct Answer: B
Rationale: Permanent ink (B) is required for Kardex to ensure legible, lasting records, per legal standards. Pencil (A) erases, felt/fountain pens (C) smudge, markers (D) fade. B ensures accuracy, making it correct.