Nokea
Which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Partial thromboplastin time
- B. Potassium level
- C. Lee-White clotting time
- D. Fibrin split product
Correct Answer: A
Rationale: Partial thromboplastin time (PTT) is essential before administering alteplase to assess bleeding risk, as it is a thrombolytic. Potassium levels and other tests are less relevant in this context.
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A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
- A. Sure, I have time; I can do it for you.'
- B. You'll have to wait; I don't have time now.'
- C. Can your family do it for you?'
- D. Get your laundry; I'll show you how the machine works.'
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
- A. Fatigue
- B. Dyspnea
- C. Bradycardia
- D. Muscle cramps
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
How many mLs will you administer to the client after you use 3.3 mL of normal saline to reconstitute a medication that will yield 12 mg per mL and the doctor's order is as follows. Doctor's order: 25 mg of medication BID
- A. 1.9 mL
- B. 2.0 mL
- C. 2.5 mL
- D. 2.1 mL
Correct Answer: D
Rationale: To calculate: 25 mg ÷ 12 mg/mL = 2.083 mL, rounded to 2.1 mL for practical administration.
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.