A client with atrial fibrillation who is receiving maintenance
therapy of warfarin sodium has a prothrombin time (PT) of 35
seconds and an international
... [Show More] normalized ratio (INR) of 3.5. On
the basis of these laboratory values, the nurse anticipates which
prescription?
A. Adding a dose of heparin
sodium
B. Holding the next dose of
warfarin
C. Increasing the next dose of
warfarin
D. Administering the next dose of
warfarin
The nurse is performing an admission assessment on a
client with a diagnosis of detached retina. Which sign or
symptom is associated with this eye disorder?
A. Total loss of vision
B. Pain in the affected eye
C. A yellow discoloration of the
sclera
D. A sense of a curtain falling
across the field of vision
The nurse is monitoring a client in active labor and notes
that the client is having contractions every 3 minutes that last
45 seconds. The nurse notes that the fetal heart rate between
contractions is 100 beats/minute. Which nursing action is most
appropriate?
A. Notify the health care provider
(HCP).
B. Continue monitoring the fetal
heart rate.
C. Encourage the client to continue
pushing with each contraction.
D. Instruct the client's coach to
continue to encourage breathing
techniques.
What is the most appropriate nursing action to help manage
a manic client who is monopolizing a group therapy session?
A. Ask the client to leave the group
for this session only.
B. Refer the client to another group
that includes other manic clients.
C. Tell the client to stop
monopolizing in a firm but
compassionate manner.
D. Thank the client for the input, but
inform the client that others now
need a chance to contribute.
The nurse working in a long-term care facility is assessing a client who
is experiencing chest pain. The nurse should interpret that the pain is
most likely caused by myocardial infarction (MI) on the basis of what
assessment finding?
A. The client is not experiencing dyspnea.
B. The client is not experiencing nausea or
vomiting.
C. The pain has not been relieved by rest and
nitroglycerin tablets.
D. The client says the pain began while she was
trying to open a stuck dresser drawer.
The nurse identifies that a client is having occasional
premature ventricular contractions (PVCs) on the cardiac
monitor. The nurse reviews the client's laboratory results
and determines that which result would be consistent
with the observation?
A. Serum chloride level of 98 mEq/L (98
mmol/L)
B. Serum sodium level of 145 mEq/L
(145 mmol/L)
C. Serum calcium level of 10.5 mg/dL
(2.75 mmol/L)
D. Serum potassium level of 2.8 mEq/L
(2.8 mmol/L)
The nurse creating a plan of care for the client demonstrating
paranoia should include which interventions in the plan of care?
Select all that apply.
A. Ask permission before touching the client
B. Provide a warm, social approach to the
client
C. Eliminate all unnecessary physical contact
with the client
D. Defuse any anger or verbal attacks with a
nondefensive stance
E. Use simple and clear language when
communicating with the client. [Show Less]