NCSBN PRACTICE QUESTIONS TEST BANK #3 Questions & Answers 100% Correct(SCORED A+)

Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? - ANSWERRecognize that this is a therapeutic level. For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually one and a half to two times the normal level. The nurse on a telemetry unit is assessing orthostatic vital signs on a client with cardiomyopathy. The client's systolic blood pressure decreased from 145 to 110 mmHg between the supine and upright positions. The client's heart rate increased from 72 to 96 bpm during that time. The client reports feeling lightheaded when standing up. Which action should the nurse implement? - ANSWERIncrease the client's PO fluid intake for the next 2 hours. The client is experiencing postural hypotension. Postural hypotension is a decrease in systolic blood pressure of at least 15 mmHg, accompanied by an increase in heart rate of 15 to 20 beats above the baseline with a change of position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, and must be instituted very cautiously. The client with cardiomyopathy will also be sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension. The nurse working in an intensive care unit is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the