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What should the nurse monitor when caring for a client receiving anticoagulant therapy?

  • A. Monitor platelet count
  • B. Monitor INR levels
  • C. Monitor bleeding
  • D. Monitor renal function
Correct Answer: B

Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications.

Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy.

Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy.

Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.

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What should be the nurse's first action when caring for a client with a traumatic amputation?

  • A. Apply pressure and elevate the limb
  • B. Stop the bleeding and control shock
  • C. Place the client in a Trendelenburg position
  • D. Place the client in a sitting position
Correct Answer: A

Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications.

Summary of why other choices are incorrect:
B: Stopping bleeding and controlling shock can be important but not the first action.
C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding.
D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.

What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?

  • A. Administer albuterol
  • B. Administer antihistamines
  • C. Monitor for signs of infection
  • D. Administer epinephrine
Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.

The major electrolytes in the extracellular fluid are:

  • A. potassium and chloride
  • B. potassium and phosphate
  • C. sodium and chloride
  • D. sodium and phosphate
Correct Answer: C

Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.

What assessment framework provides additional modesty for clients, such as teenage girls?

  • A. Body systems
  • B. Functional
  • C. Focused
  • D. Head to toe
Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?

  • A. Administer oxygen
  • B. Administer corticosteroids
  • C. Monitor serum glucose
  • D. Administer pain relief
Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.

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