Nokea
Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease?
- A. Clopidogrel.
- B. Streptokinase.
- C. Protamine sulfate.
- D. Enoxaparin.
Correct Answer: A
Rationale: Clopidogrel (A), an antiplatelet, is used in arterial occlusive disease to prevent thrombosis. Streptokinase (B) is a thrombolytic, protamine (C) reverses heparin, and enoxaparin (D) is for DVT.
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The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first?
- A. Assist the client to dangle the legs off the side of the bed.
- B. Assess and maintain pressure bandages on the affected leg.
- C. Apply a sequential compression device to the affected leg.
- D. Administer the prescribed prophylactic intravenous antibiotic.
Correct Answer: B
Rationale: Assessing/maintaining pressure bandages (B) prevents bleeding post-vein ligation. Dangling (A) is premature, compression devices (C) are secondary, and antibiotics (D) follow assessment.
Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
Which assessment finding in a client with a pacemaker requires immediate action? Select all that apply.
- A. Heart rate of 50 beats per minute
- B. Pain at the insertion site
- C. Fever of 101°F
- D. Hiccups that persist
- E. Swelling at the pacemaker site
- F. Mild bruising at the site
Correct Answer: A,C,D,E
Rationale: Low heart rate, fever, persistent hiccups, and swelling suggest pacemaker malfunction or infection, requiring immediate attention.
The client with atrial fibrillation is prescribed warfarin. Which laboratory value should the nurse monitor?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Red blood cell count
Correct Answer: B
Rationale: Warfarin's anticoagulant effect is monitored using INR to ensure therapeutic levels and prevent bleeding or clotting.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.