Nokea
Which of the following laboratory tests should the nurse monitor when the client is receiving warfarin sodium (Coumadin) therapy?
- A. Partial thromboplastin time (PTT).
- B. Serum potassium.
- C. Arterial blood gas (ABG) values.
- D. Prothrombin time (PT).
Correct Answer: D
Rationale: Warfarin therapy requires monitoring prothrombin time (PT) to assess anticoagulation effectiveness.
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The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse should tell the client that this therapy will most likely improve which problem?
- A. Double vision
- B. Difficulty breathing
- C. Urinary incontinence
- D. Prickling sensation in the legs
Correct Answer: B
Rationale: Plasmapheresis is a process that separates the plasma from the blood elements so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually 3 to 5 treatments are required. This therapy is not indicated for the reasons listed in any of the other options.
A client with angina shows the nurse her nitroglycerin (Nitrostat) that she carries in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept in:
- A. The refrigerator.
- B. A cool, moist place.
- C. A dark container to shield from light.
- D. A plastic bag where it is readily available.
Correct Answer: C
Rationale: Nitroglycerin is sensitive to light and heat, which can degrade its potency. Storing it in a dark container protects it from light exposure, ensuring effectiveness.
The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother?
- A. It is an acquired cell-mediated immunodeficiency disorder.
- B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
- C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology.
- D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
Correct Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.
A client with type 2 diabetes is prescribed metformin. Which laboratory value should the nurse monitor?
- A. Serum creatinine.
- B. Hemoglobin A1c.
- C. Platelet count.
- D. Serum sodium.
Correct Answer: A
Rationale: Metformin can affect renal function, so monitoring serum creatinine is essential to assess kidney function.