NUR 111 Final Exam Questions and Answers with Complete Solutions Graded A 2024

A nurse is caring for a patient who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the patient that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement. B When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? A) friction B) necrosis of tissue C) ischemia D) shearing force D What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings? A) Change position at least once each shift. B) Implement a turning schedule every 2 hours. C) Use ring cushions for heels and elbows. D) Do not turn, use pressure-relieving support surface. B A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) full-thickness skin loss B) skin pallor C) blister formation D) eschar formation A During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers .C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery. D A nurse assessing a patients wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) clear, watery blood B) large numbers of red blood cells C) mixture of serum and red blood cells D) white blood cells, debris, bacteria D A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) Oh, for gosh sakes it doesnt look that bad! B) I understand, but you are going to have to look someday. C) I respect your wish not to look at it right now. D) You wont be able to go home until you look at it. C Of the many topics that may be taught to patients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) taking medications as prescribed B) proper intake of food and fluids C) thorough hand hygiene D) adequate sleep and rest C A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid. C What would a nurse expect to administer for a Heparin overdose? A) Urokinase B) Pentoxifylline C) Thrombin D) Protamine sulfate D The nurse is monitoring a pt's Heparin infusion. What potential nursing diagnosis should the nurse prioritize when planning assessments? A) Deficient Knowledge regarding drug therapy B) Ineffective Tissue Perfusion (Total Body) related to blood loss C) Risk for Imbalanced Fluid Volume related to third-spacing D) Risk for Infection related to bone marrow suppression B The nurse is caring for a pt taking Warfarin whose PT is four times the control. What is the nurse's best action, if ordered by the provider? A) Administer vitamin K B) Administer protamine sulfate C) Redraw another PT D) Administer the next dose of Warfarin A The federal organization "OSHA" stands for: A. Occupational Standards for Health Associations B. Occupational Safety Health Administration C. Occupational Safety and Health Act D. Occupational Safety Health Association B True or false? Warfarin typically takes 3 days to achieve its onset of action. True Which statement is not true about HIV, HBV, and health care workers? A. Neither HIV or HBV can be fatal. B. Health care workers are at greater risk for HBV than HIV. C. There has been an increase in the number of HIV carriers. D. HBV is more common than HIV. A A nurse would anticipate the need for an increased dosage of warfarin if the patient was also receiving: A. Carbamazepine B. Clofibrate C. Amiodarone D. Danazol A. Carbamazepine Carbamazepine decreases the anticoagulant effects of warfarin necessitating an increased dose of warfarin. Clofibrate, amiodarone, and danazol increase the bleeding effects of warfarin, necessitating a decreased dosage of warfarin. A nurse is providing patient teaching to a patient who has been experiencing unstable angina. What will the nurse's explanation of this condition include? A) A coronary vessel has become completely occluded and is unable to deliver blood to your heart. B) The pain is caused by a spasm of a blood vessel, not just from the vessel narrowing. C) There is serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart. D) Your body's response to a lack of oxygen in the heart muscle is pain. C Feedback:Unstable angina is described as increased narrowing of coronary arteries with the heart experiencing episodes of ischemia even at rest. If a coronary vessel is completely occluded and unable to deliver blood to the cardiac muscle, a myocardial infarction has occurred. Prinzmetal's angina is an unusual form of angina caused by spasm of the blood vessel and not just by vessel narrowing. Although pain is the body's response to ischemia in the heart muscle, this description could encompass angina or a myocardial infarction and is not specific enough to explain the condition. A nurse is teaching the patient newly prescribed sublingual nitroglycerin how to take the medication. What will the nurse instruct the patient to do first? A) To check his radial pulse B) To place the tablet in the buccal cavity C) To take a sip of water D) To lie down for 15 minutes before administration C The nurse should instruct the patient to take a sip of water to moisten the mucous membranes so the tablet will dissolve quickly. The patient does not need to take his pulse or lie down before drug administration. For sublingual administration, the patient will place the tablet under his tongue and not in the buccal cavity (cheek area). What statements by the 54-year-old patient indicates an understanding of the nurse's teaching about how to take sublingual nitroglycerin? A) "A headache means a toxic level has been reached." B) "I can take up to 3 tablets at 5-minute intervals." C) "I can take as much nitroglycerin as I need because it is not habit forming." D) "If I become dizzy after taking the medication, I should stop taking it." B Sublingual nitroglycerin may be taken at 5-minute intervals up to a maximum of three doses to relieve anginal chest pain. Headaches are very common due to vasodilation and do not indicate a toxic level. Nitroglycerin causes significant peripheral vasodilation in addition to its therapeutic effects of coronary artery dilation so no more than three tablets should be taken, even though it is not habit forming. Dizziness could be an adverse effect of the drug or a manifestation of inadequate cardiac output, but it would not indicate the patient should stop taking it. The nurse is caring for a patient who takes nitroglycerin sublingually. When providing patient education, the nurse would tell the patient that she can expect relief of chest pain within what period of time? A) 1 to 3 minutes B) 5 to 10 minutes C) 15 to 20 minutes D) 30 to 60 minutes A Nitroglycerin acts within 1 to 3 minutes. The nurse is caring for a patient who is taking a calcium-channel blocker. What adverse effects would the nurse caution this patient about? A) Hypertension and tachycardia B) Headache and dizziness C) Itching and rash D) Nausea and diarrhea B The adverse effects associated with these drugs are related to their effects on cardiac output and on smooth muscle. Central nervous system (CNS) effects include dizziness, light-headedness, headache, and fatigue. Gastrointestinal (GI) effects can include nausea and hepatic injury related to direct toxic effects on hepatic cells. Cardiovascular effects include hypotension, bradycardia, peripheral edema, and heart block. Skin effects include flushing and rash. The adverse effects do not, however, include diarrhea, hypertension, tachycardia, or itching. Which body fluids are potential sources of HIV, HBV, HCV infection? A. Blood, sweat, tears, vaginal secretions B. Blood, saliva, nasal secretions. C. Blood, semen, body fluids containing blood. D. Blood, stool, urine, semen. C Identify the true statement related to immunization against HBV and health care workers. A. Immunization is not recommended for any health care workers. B. Immunization is recommended for all workers. C. Immunization is a requirement. D. Immunization is recommended for individuals exposed to blood or potentially infectious agents. D The first action after an exposure is: A. Consult an attorney B. Wash the exposed area. C. Consult a medical care provider. D. Complete an incident report. B The most common chronic bloodborne infection in the US is: A. HBV B. Syphilis C. HCV D. HIV C True or False: Items that have blood on them should be discarded in devices labeled biohazard. True The nurse has weighed a new client during the admission assessment. How does this action best contribute to safe medication administration? A. Provides baseline for changes in fluid resistance. B. Confirms appropriate use of subcutaneous or intramuscular injections. C. Allows the care team to prescribe the correct medication dose D. Identifies nutritional deficiencies that may affect drug dosage. C. Allows the care team to prescribe the correct medication dose SIDE NOTE: Dosage of medication is often calculated based on the client's weight, so getting clients' weight wrong could cause a med error. The nurse should consider teratogenic effects when caring for what clients? Select all that apply. A. 81-year-old with chronic heart failure B. 37-year-old female taking fertility drugs C. 41-year-old male who is post-bone marrow transplant D. 29-year-old receiving prenatal care during first trimester of pregnancy E. 50-year-old post menopausal female being treated for acute renal failure. B, D A client was prescribed a 10-day course of antibiotics to treat a sinus infection. With symptom relief after 3 days of medications, the client stopped taking the antibiotic. What is a priority nursing diagnosis for this client? A. Knowledge deficit B. Non-compliance C. Risk for injury D. Chronic confusion B (the priority issue is the client's non-adherence to treatment/drug regimen) Which is a correctly written client outcome? A. The client will eliminate a soft, formed stool B. The client will ambulate 10ft (3m) with a walker by October 12. C. The client correctly self-administers the morning dose of insulin. D. The client understands what food are low in sodium. B When a client achieves their expected outcome in the care plan, which action should the nurse do first? A. Create a new care plan. B. Continue the care plan. C. Modify the care plan. D. Terminate the care plan D The nurse is caring for an older adult client who is prescribed a benzodiazepine. When planning the client's assessment, the nurse should be aware of what possible adverse effect? A. Acute Renal Failure B. Dysuria (painful urination) C. Unpredictable reactions D. Epistaxis (nosebleeds) C Rationale: Use benzos with caution because of the possibility of unpredictable reactions and in clients with renal or hepatic dysfunction, which may alter the metabolism and excretion of these drugs, resulting in direct toxicity. Dosage adjustments usually are needed for such clients. Acute renal failure, dysuria, and epistaxis are not commonly related to therapy with these meds in the elderly. The nurse is caring for a client who does not have a respiratory disorder but has been prescribed acetylcysteine. What is an additional indication for acetylcysteine? A. Treatment of stomach ulcers. B. Antidote for acetaminophen poisons C. Treatment of bronchospasm D. Conversion of cardiac rhythm irregularities B Acetylcysteine is used orally to protect liver cells from being damaged during episodes f acetaminophen toxicity because it normalizes hepatic glutathione levels and binds with a reactive hepatotoxic metabolite of acetaminophen. A client with a persistent, dry, non-productive cough has been diagnosed with chronic pharyngitis (sore throat). The client should benefit the most from what medication category? A. Antitussives B. Oral decongestants C. Nasal Sprays D. Mucolytics A. Antitussives Rational: Antitussives are drugs that suppress the cough reflex. Persistent coughing can be exhausting and can cause muscle strain and further irritation of the respiratory tract. A client has taken a benzodiazepine for one year following a divorce. During an annual physical, the client states, "I decided it was time to move on, so I stopped this drug three days ago." The nurse then assesses the client for what symptoms of withdrawal? A. Sedation and Drowsiness B. Trembling, muscle cramps, and sweating C. Decreased libido (sex drive) and urinary hesitancy D. Dry mucous membranes and constipation B. Trembling, muscle cramps, and sweating Rational: taper dose gradually after long-term therapy especially in epileptic patients. Acute withdrawal could precipitate seizures in these patients. May also cause withdrawal symptoms. What client education would the nurse include following administration of a sublingual medication? A. "Chew the pill so it will dissolve faster" B. "Avoid dairy products while taking this med C. Swallow this tablet with a full glass of water D. Allow the tablet to slowly dissolve beneath your tongue D A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A. Assists in moving upper chest muscles B. Prolongs expiration reducing airway resistance C. Replaces use of incentive spirometry D. Reduces need for prn pain meds B. Prolongs expiration reducing airway resistance Rationale: Pursed lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. The nurse is preparing to complete a head to toe assessment on a client. The most important intervention immediately prior to beginning the assessment would be? A. Provide privacy without environmental distractions when performing the assessment B. Ask the client about an appropriate time to complete the assessment C. Have the client remove all clothing and don a patient gown D. Always involve family members in collecting information about the client A. Provide privacy without environmental distractions when performing the assessment Rationale: The nurse and client should be in a room (or area) that is private, quiet, and warm enough to prevent chilling, and it should have adequate lighting either by sunlight or overhead fixtures. Family members may remain, especially if they are needed to explain activities to the client. The nurse noted that a client just received bad news, was crying, and did not want to speak to anyone. What is the correct term for this response to this news? A. Adaptation B. Homeostasis C. Coping Mechanisms D. Defense Mechanism C. Coping Mechanism Rationale: When a person is in a threatening situation immediate responses occur. Those responses, which are often involuntary, are called coping responses. The change that takes place as a result of the response to a stressor is adaptation. The nurse uses the ISBARR method of hand off the communication to the health care team. Which of the following might be listed under the "B" of the acronym? A. Vital Signs B. Client Request C. Further Testing D. Mental Status D. Mental Status Rationale: ISBARR stands for introduction, situation, background, assessment, recommendations, and readback. ISBARR provides a consistent method for hand- off communication that is clear, structured, and easy to use. Your client is a recent college graduate working at a fast paced engineering firm for approximately 4 months. The client recognizes there have been many stressful days on the job and makes a decision to participate in activities to reduce stress. What activities would you recommend to reduce stress for your client? Select all that apply. A. Practice mediation B. Taking a sleeping pill to ensure getting at least 7 hours of sleep C. Drink two to three ounces of alcohol each night after work D. Participate in an enjoyable hobby, such as painting E. Walk in neighborhood for 3 to 4 days/week A, D, E The wristband is an important safety component used during client stays. Which organization's guidelines require the nurse to accurately identify a client using the wristband when providing care? A. ANA (American Nurses' Association) B. TJC (The Joint Commission) C. NANDA (North American Nursing Diagnosis Association) D. HIPAA (Health Insurance Portability and Accountability Act) B. TJC When nurses use the principle of during client care, avoidance of all harm is priority. A. Autonomy B. Fidelity C. Nonmaleficence D. Justice C. Nonmaleficence The nurse has donned a sterile glove on one hand and is preparing to don the other sterile glove. What would be the next step? A. Use the fingers and thumb to grasp the edges of the cuff of the second glove B. Use the thumb and index finger to grasp the cuff of the second glove C. Hold the second glove in the palm of the gloved hand D. Place the fingers of the gloved hand under the cuff of the second glove. D. Place the fingers of the gloved hand under the cuff of the second glove A wound and ostomy care nurse (WOCN) is teaching a client to care for a new colostomy. The client's understanding of teaching is verified when the client states? A. "I need to call my provider if the peristomal skin is intact." B. "I should call my surgeon if the stoma is not drying out." C. "I should change the wafer every am at 1000." D. "It is normal if the stoma is beefy red and moist." D. "It is normal if the stoma is beefy red and moist." A student is collecting a sterile urine specimen from an indwelling catheter. Which of the following is the correct way to obtain the specimen? A. Aspirate urine from the collection port on the catheter tubing. B. Aspirate urine from the collection bag. C. Obtain urine from the collection bag. D. Removing the catheter and ask the client to void. A. Aspirate urine from the collection port on the catheter tubing. The nurse is aware that some clients have difficulty swallowing solid preparations of meds. What nursing intervention would be the most appropriate to assist a geriatric client with difficulty swallowing? A. Crush an enteric-coated tablet and give with milk. B. Crush a prolonged-release tablet into fine powder C. Break a scored tablet. Give first half then give the second half 30 sec. to a min. later. D. Open a sustained-release capsule and mix the contents with applesauce C. Break a scored tablet. Give first half then give the second half 30 sec. to a min. later-- Scored tablets can be broken and administered separately. This makes swallowing the pill easier because it is not as large. A client is to receive metoclopramide (Reglan) for nausea. What statement by the client leads the nurse to believe that the client has understood the nurse's teaching? A. "I will take OTC minerals while I am taking this medication." B. "I may be drowsy as a result of taking this medication." C. "During episodes of nausea, I will drink lots of water." D. "This medication should be taken on a full stomach." B. "I may be drowsy as a result of taking this medication." Rationale: Adverse effects include drowsiness, fatigue, restlessness, extrapyramidal symptoms, and diarrhea A client with acid reflux has an order for pantoprazole (Protonix), 40mg po daily. In order to achieve maximum therapeutic effect, the nurse schedules the medication for which of the following times? A. 1000 hours B. 2200 hours C. One hour after breakfast D. One hour before breakfast D. One hour before breakfast The provider instructs the client to take psyllium (Metamucil) 1 tablespoon daily in 8 oz of water. Which client outcome would be the best measure of a therapeutic response from this medication? A. Client bowel sounds progress from hypoactive to absent within 3 hours B. Client reports nausea followed by projectile vomiting within 1 hour. C. Client produces soft, formed bowel movement within 2 days. D. Client complains of 3 liquid stools within 8 hours C. Client produces soft, formed bowl movement within 2 days. Rationale: Psyllium is a natural substance that forms a gelatin-like bulk of the intestinal contents. This agent stimulates local activity. It is considered milder and less irritating than many other bulk stimulants. Clients must use caution and take it with plenty of water because it absorbs large amounts of water and produces stools of gelatin-like consistency. As anti-infectives continue to be an area of concentration for pharmaceutical manufacturers and as providers are encouraged to prescribe these medications, nurses are caring for an increasing number of clients who have developed antibiotic resistance. What principles should the nurse and the other members of the health care team follow in attempts to prevent antibiotic resistance? Select all that apply. A. Teach clients not to save antibiotics for self-medication in the future B. Avoid broad-spectrum antibiotics when treating trivial or viral infections C. Treat all infections with anthelminthic or antivirals whenever possible D. Use narrow-spectrum agents if they are likely to be effective E. Perform culture and sensitivity testing immediately after starting a course of antibiotics A. Teach client's not to save antibiotics for self-medication in the future-- it is vital to complete the fill course of treatment to increase the chances of eradication of the organism B. Avoid broad-spectrum antibiotics when treating trivial or viral infections-- by treating with broad spectrum it attacks lots of bacteria. With repeated exposure, bacteria mutate and attempt to figure out a way to survive despite treatment. These broad spectrums no longer work with specific strains of bacteria. D. Use narrow-spectrum agents if they are likely to be effective. When documenting subjective client data, the nurse should: A. Verify the information with the client's family prior to documentation B. Document everything that was said by the client in an unstructured manner C. Use the client's own words placed in quotation marks. D. Record the information using generic wording. C. Use the client's own words placed in quotation marks The nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? A. Do not recap the needle; placed in a puncture-resistant container B. Break off the needle, place in the barrel, and throw it in a the trash. C. Recap the needle; place it in a puncture-resistant container D. Take off the needle and throw the syringe in the client's trash can A. Do not recap the needle; place it in a puncture-resistant container Rationale: after use, needles and syringes are placed in a puncture-resistance container without being recapped. This prevents needlestick injuries, because most occur during recapping. The client is currently taking medications for chronic pain management secondary to rheumatoid arthritis. At an urgent care facility, the client presents with reports of dizziness, mental confusion, and difficulty hearing. What assessment is most appropriate by the nurse based upon these symptoms? A. Use of acetaminophen B. Use of salicylates C. Exacerbation of rheumatoid arthritis D. Allergy status B. Use of salicylates Rationale: salicylism can occur with high dosage of aspirin, Dizziness, ringing in the ears, difficulty hearing, nausea, vomiting, diarrhea, mental confusion, and lassitude can occur. A nurse is preparing to administer a prescribed antibiotic and is aware that the medication is selectively toxic. What does the nurse understand about this medication? A. It eliminates bacteria by interrupting protein synthesis and damaging the pathogen's cell wall. B. It kills invading bacteria by interfering with the pathogen's ability to reproduce. C. It interferes with a biochemical reaction common to many different organisms. D. It is able to kill foreign cells without causing significant harm to the client's own body cells. D. It is able to kill foreign cells without causing significant harm to the client's own body cells. Rationale: The choice of antibiotics in a clinical situation is determined by assessing which drug will affect the causative organism and lead to the fewest adverse effects. A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which agent is most likely the cause of the infection? A. Virus B. Bacteria C. Fungi D. Spores B. Bacteria Rationale: Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi. Bacteria are the most significant and most commonly observed infection- causing agents in health care institutions. A client is on isolation because she acquired a MRSA infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A. Healthcare-associated (HAI) B. Antimicrobial C. Viral D. Septicemia A. Healthcare-associated (HAI) Rationale: for various reasons and sometimes despite best efforts, certain clients in health agencies develop infections that were not noted to be present on admission. A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? A. With sterile forceps or hands wearing sterile gloves B. By clean hands wearing clean latex gloves C. By carefully handling them with clean hands. D. With clean forceps that touch only the outermost part of the item A. With sterile forceps or hands wearing sterile gloves Rationale: once a sterile field is established, objects on a field may only be handled by using sterile forceps or with hands wearing sterile gloves. A client has a significant laceration on the left arm. Since the injury, the client has had muscle and joint aches, a low grade fever, and sleepiness. The nurse should attribute this to what component of the inflammatory response? A. Leukotriene activity B. Interferon activity C. Bacterial toxins D. Phagocytosis A. Leukotriene activity Rationale: The leukotrienes affect the brain to induce slow, wave sleep, believed to be an important energy conservation measure for fighting the invader. They also cause muscle and joint pain, common signs and symptoms of various inflammatory diseases, which also cause reduced activity and save energy. A nurse practitioner is teaching a health class in the local community center. The nurse should identify what group as having the greatest risk for hepatitis B? A. Police Officers B. Restaurant workers C. Healthcare workers D. Elementary School teachers C. Healthcare workers Rationale: Healthcare workers are at especially high risk for contracting hepatitis B due to needle sticks and contact with the blood of infected clients. A home health nurse has a caseload of several postoperative clients. Which on would be most likely to require a longer healing time? A. An infant B. A middle adult C. A young adult D. An older adult D. An older adult Rationale: An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re- dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order. A. Remove the soiled dressing wearing clean gloves B. Dry the surrounding tissue with gauze C. Insert the culture swab deep into the wound wearing clean gloves D. Clean the wound wearing sterile gloves and using sterile supplies E. Using a different pair of gloves, place a clean dressing on the wound ADBCE When auscultating an apical pulse, what is the site to be used? A. Left fifth intercostal space midclavicular line B. Left third intercostal space C. Right fifth intercostal space midclavicular line. D. Right third intercostal space A What is the best practice for the nurse to use to promote infection control in the hospital? A. Avoid touching any object in the hospital, including door knobs. B. Practice hand hygiene by washing with soap and water and/or alcohol-based rubs. C. Avoid contact with soiled linen by asking the family to perform all client care. D. Take prescribed antibiotics to remain infection-free while working. B During an assessment, the nurse uses the method of inspection. What is needed to perform this skill? A. High quality stethoscope. B. Electronic thermometer C. Documentation skill checklist D. Senses of hearing and sight D The nurse is preparing to perform an abdominal assessment on a client. Which position would best accommodate this assessment? A. High Fowler's B. Supine C. SIMS D. Prone B How can a needle stick be avoided? A. Discard used needles in appropriate containers. B. Do not recap needles. C. Use safer needle devices D. All of the above D Most health care workers are exposed to bloodborne pathogens by: A. Mucous membrane contact B. Puncture wounds. C. Environmental contact. D. Skin Contact. B You are caring for a patient who is taking Warfarin (Coumadin) to prevent venous thrombosis. You should explain that taking the drug requires daily blood samples to monitor of which of the following laboratory tests? a. Fibrinogen b. PT/INR c. Platelets d. aPTT PT/INR PT - prothrombin time INR - international normalized ratio At the start of warfarin therapy, you should monitor PT and INR daily and adjust the dosage to maintain an INR of 2 to 3. Monitor the patient for indications of bleeding such as abdominal pain, black tarry stools, or nosebleeds. aPTT - activated partial thromboplastin time; parameter to assess every 4 to 6 hrs initially and then daily for patients receiving continuous IV heparin. True or False: If you are exposed to a bloodborne pathogen, you are not automatically infected. True While a pt is receiving a general anesthetic, he or she must be continually monitored because: A) The pt has no pain sensation B) Generalized CNS depression affects all body functions C) The pt cannot move D) The pt cannot communicate B A pt is receiving Warfarin. What would the nurse monitor to determine the effectiveness of therapy? Select all that apply. A) Whole blood clotting time B) Prothrombin time C) International normalized ratio D) Partial thromboplastin time E) Vitamin K levels B,C What type of insulin would the nurse administer if the fastest therapeutic effects are needed? A) Lispro (Humalog) B) Aspart (NovoLog) C) Regular (Humulin R) D) Glulisine (Apidra) D Glulisine has an onset of 2 to 5 minutes and peaks in 30 to 90 minutes so it has the fastest onset of action. Lispro has an onset in 15 minutes and also peaks at 30 to 90 minutes. Aspart takes 10 to 20 minutes for onset and peeks in 1 to 3 hours. Regular insulin has a 30 to 60 minute onset and peaks in 2 to 4 hours. The nurse admits a patient to the emergency department and recognizes the patient is in diabetic ketoacidosis (DKA) when what manifestations are assessed? (Select all that apply.) A) Fruity breath B) Edema C) Dehydration D) Agitation E) slow and deep respiration's A, C, E Signs of impending dangerous complications of hyperglycemia such as DKA include the following: fruity breath as the ketones build up in the system and are excreted through the lungs; dehydration as fluid and important electrolytes are lost through the kidneys; slow and deep respirations (Kussmauls respirations) as the body tries to rid itself of high acid levels; loss of orientation and coma rather than agitation are to be expected. Edema is not a sign of DKA. What outcome would best indicate the nurses teaching was effective and that drug therapy was appropriate? A) The patient can explain how to take the medication. B) The patient demonstrates the correct procedure for monitoring blood sugar. C) The patient follows an appropriate diet. D) Blood glucose level is stable with no diabetic complications. D The single best indicator, and the goal of treatment, is to help the patient maintain a stable blood glucose level so as to be able to avoid any complications. For the patient to maintain a stable blood glucose level, he needs to understand how to take his medication, to check his blood sugar level, and to follow an appropriate diet, but the best indicator is the stable glucose level. A patient is brought to the emergency department with severe hypoglycemia. What drug would the nurse prepare to administer intravenously? A) Diazole (Hyperstat) B) Glyburide (DiaBeta) C) Glucagon (GlucaGen) D) Insulin (Humulin R) C This patient will need a glucose-elevating agent. Glucagon (GlucaGen) is given parenterally only and is the preferred agent for emergency situations. Diazole is also a glucose-elevating agent but is only administered so it would take longer to take effect. Insulin would be administered for hyperglycemia. Glyburide is an oral antidiabetic agent, which is a second-generation sulfonylurea, and is administered for hyperglycemia. The nurse suspects the diabetic patient may be having a hypoglycemic reaction when what manifestation is assessed? A) Dry, flaky skin B) Diaphoresis C) Flushing of the face D) Fruity breath B Diaphoresis and cool clammy skin are signs of hypoglycemia. A fruity breath is seen with ketoacidosis. Flushing of the face is associated with hyperglycemia. Select all that apply: A nurse would anticipate the use of general anesthetics for which of the following reasons? A) To produce analgesia B) To produce amnesia C) To activate the reticular activating system D) To block muscle reflexes E) To cause unconsciousness F) To prevent nausea A B D E A 10-year-old child has edema caused by a heart defect. The patient is taking furosemide (Lasix). The dosage is 3 mg/kg/d. The child weighs 76 pounds. How many mg does the child receive in each dose? Round to the nearest whole number. A) 20 mg B) 50 mg C) 105 mg D) 104 mg D A patient comes to the clinic for a 1-month follow-up appointment. The patient tells the nurse he or she has been taking chlorothiazide (Diruil) for a month and now has leg cramps and "feels tired all the time." What will the nurse consider as the cause of the patient's symptoms? A) Hypercalcemia B) Hypocalcemia C) Hyperkalemia D) Hypokalemia D A patient has just begun to take a prescribed diuretic. Why would the nurse tell the patient to drink 8 to 10 glasses of water daily (unless it is counterindicated)? A) To decrease the action of the renin-angiotensin cycle B) To make more concentrated plasma C) To dilute the urine D) To avoid rebound edema D A patient who was recently prescribed spironolactone calls the clinic and complains that he is not urinating as much as he did when he first started taking this medication. What would be an appropriate question for the nurse to ask this patient? A) "Are you taking a salicylate?" B) "Are you taking acetaminophen?" C) "Are you taking ibuprofen?" D) "Are you using a lot of salt?" A