Which lab value is critical for monitoring warfarin therapy?
- A. Monitor INR
- B. Monitor platelet count
- C. Monitor sodium levels
- D. Monitor calcium levels
Correct Answer: A
Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.
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What is the initial action a healthcare provider should take for a patient with chest pain?
- A. Administer oxygen
- B. Administer nitroglycerin
- C. Administer morphine
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct initial action for a patient with chest pain is to administer oxygen. Chest pain can be caused by insufficient oxygenation, and providing oxygen helps alleviate the pain by increasing oxygen levels in the blood. Administering nitroglycerin or morphine may be appropriate based on the underlying cause of the chest pain, but oxygen should be given first to ensure the patient's oxygen supply is adequate. Surgery is not typically the initial intervention for chest pain.
What is the priority nursing action for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Administer corticosteroids
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.
If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
A healthcare professional is reviewing the laboratory results of a client who has chronic kidney disease. Which of the following findings should the healthcare professional report to the provider?
- A. Serum potassium 4.5 mEq/L
- B. Serum calcium 9.2 mg/dL
- C. Serum creatinine 2.5 mg/dL
- D. Serum albumin 3.5 g/dL
Correct Answer: C
Rationale: Elevated serum creatinine levels indicate impaired kidney function. As kidney disease progresses, the kidneys are less able to filter waste products, leading to an increase in creatinine levels. Therefore, a high serum creatinine level of 2.5 mg/dL should be reported to the provider for further evaluation and management. Choices A, B, and D are within normal ranges and do not directly signify worsening kidney function in this context.
What is the best way to monitor fluid balance in a patient with kidney disease?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Check urine output
Correct Answer: A
Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.