Nokea
You are caring for a client with deep vein thrombosis who is on Heparin IV. The latest APTT is 50 seconds. If the laboratory normal range is 16-24 seconds, you would anticipate
- A. maintaining the current heparin dose
- B. increasing the heparin as it does not appear therapeutic
- C. giving protamine sulfate as an antidote
- D. repeating the blood test 1 hour after giving heparin
Correct Answer: A
Rationale: maintaining the current heparin dose. The range for a therapeutic APTT is 1.5-2 times the control. Therefore the client is receiving a therapeutic dose of Heparin.
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The client has the following arterial blood gases: pH 7.19, Paco2 33, Pao2 95, and HCO3 19. Which medication would the nurse prepare to administer based on the results?
- A. Intravenous sodium bicarbonate.
- B. Oxygen via nasal cannula.
- C. Epinephrine intravenous push.
- D. Magnesium hydroxide orally.
Correct Answer: A
Rationale: Metabolic acidosis (low pH, low HCO3) requires sodium bicarbonate to correct pH. Oxygen, epinephrine, or antacids are inappropriate.
A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?
- A. Urine output every 4 hours
- B. Blood glucose levels every 12 hours
- C. Neurological signs every 2 hours
- D. Oxygen saturation every 8 hours
Correct Answer: B
Rationale: The drug Decadron increases gluconeogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored.
The client with type 2 diabetes mellitus is prescribed glyburide (Micronase), a sulfonylurea. Which statement indicates the client understands the medication teaching?
- A. I should carry some hard candy when I go walking.
- B. I must take my insulin injection every morning.
- C. There are no side effects I need to worry about.
- D. This medication will make my muscles absorb insulin.
Correct Answer: A
Rationale: Glyburide can cause hypoglycemia; carrying candy prepares for low blood sugar during activity. Insulin, no side effects, or muscle absorption are incorrect.
The clinic nurse is teaching an adult male who has AIDS. He is receiving zidovudine. Which statement he makes indicates that he understands the medication regimen?
- A. If I get a sore throat and it is hard to swallow my capsules, I can empty the capsule into applesauce.
- B. I am hopeful that this drug will get rid of this awful disease.
- C. I understand I might need a transfusion.
- D. I should take acetaminophen (Tylenol), not aspirin, if I get a fever.
Correct Answer: D
Rationale: Zidovudine can cause bone marrow suppression; acetaminophen is safer than aspirin, which increases bleeding risk.
The nurse is administering an antacid to a client with gastroesophageal reflux disease. Which statement best describes the scientific rationale for administering this medication?
- A. This medication will suppress gastric acid secretion.
- B. This medication will decrease the gastric pH.
- C. This medication will coat the stomach lining.
- D. This medication interferes with prostaglandin production.
Correct Answer: C
Rationale: Antacids neutralize acid and coat the stomach, relieving GERD symptoms. Acid suppression, pH decrease, or prostaglandins are unrelated.