AH 2

A client is receiving warfarin. Which test results should the nurse use to determine if the daily dose of his anticoagulant is therapeutic?

A. Warfarin initially is prescribed day by day, based on international normalized ratio INR blood test results. This test provides a standard system to interpret prothrombin times.

The nurse is preparing to give a client and IV push medication through an intermittent IV set (saline lock) using a needleless system. Which actions by the nurse are most appropriate? Select all that apply

**No rationale given**

The RN is working with an experienced LPN who has been assigned several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy to the LPN? Select all that apply

**no rationale given**

Ordered: 75 ML to be infused for 45 minutes. Below is the IV tubing you have available. (10 drops/mL)

(10/45)*(75/1)= 750/45= 16.6 or 17 drops per minute

A patient has a low density lipoprotein of 175 MG/dL and a high density lipoprotein of 30 mg/dL. What teaching should the nurse implement for this patient?

A (pg 708 Lab assessment iggy book)

The nurse is preparing to administer a medication IV push. What information does the nurse need to know before beginning the infusion? Select all that apply

A B C E giving IV push medications requires specific knowledge about each drug, including dilution, rate of administration, compatibility, and monitoring. PH amd osmolarity and specific infusion site appropriate for giving this specific drug are also important to know. When giving an IV push medication it is not necessary to know whether other routes of administration are possible.

The nurse is caring for a client who needs a hypertonic IV solution. What solutions are hypertonic? Select all that apply

A C D E hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated ringer's solution. The solution of 0.45% sodium chloride are not hypertonic solutions.

The nurse has just performed an IV start on a client. After the catheter has been threaded it's full length in the clients vein which action does the nurse perform next?

A federal law enacted in 2000 requires healthcare facilities to use IV catheters with an engineered safety mechanism to prevent needlesticks which can be a source of contamination by blood-borne pathogen's. This priority action would keep the nurse safe.

D. With a PaO2 of 62 the patient has Hypoxemia consistent with PE and cyanosis.

A nurse reviews the arterial blood gas for the patient. The nurse is most concerned with which value?

A client diagnosed with atherosclerosis has been prescribed lovastatin. Which statement by the client indicates a need for further teaching?

A pg 708-9 Iggy- straight out of the book. Clients still need to change their nutrition and diet, not only rely on medication.

A 67-year-old man who had a total hip arthroplasty four days ago is being discharged to a rehabilitation facility. He had a PE several months ago and was taking warfarin sodium Coumadin 7.5 mg daily as a maintenance dose, which he stopped several days before the arthroplasty. While hospitalized he received heparin 5000 units subcutaneously twice a day. His discharge medications do not include an anticoagulant. The nurse should:

A. Failure to clarify this omission can be life-threatening because of the potential for an embolus.

A student nurse is preparing to take a blood pressure on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important?

A. Nurses should not take blood pressure on arms that have IVs because increased pressure can cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not be used for BP, none of the other options can be correct.

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard and 140 MMHG, the second sound is a swishing sound heard at 130MMHG, then a tapping sound is heard at 100 MMHG, a muffled sound is heard at 90 MMHG, and the sound disappears at 72MMHG. When recording just the systolic and diastolic readings what is the diastolic pressure?

A. When the sound disappears at 72MMHG it is known as phase 5 of KOROTKOFF'S sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely.

The nurse wants to provide community service that helps people meet goals of healthy people 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?

An important goal of HP 2020 is to increase the proportion of adults who have had their blood pressure measured with in the preceding two years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

B Constriction of the peripheral blood vessels and the resulting increase in blood pressure impair circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities.

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38, PaCO2 of 38 mm/hg, PaO2 of 86 mm/hg, and HCO3 of 23 mEq/L. What action should the nurse take in response to these results?

B The clients results fall in the normal range for pH(7.35-7.45), PaCO2 (35-45), and bicarbonate level(21-28). With acidosis the pH would be less than 7.35: with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis where as bicarbonate levels would be low if metabolic acidosis were present.

The nurse is documenting peripheral venous catheter insertion for a patient. What does the nurse include in the note? Select all that apply

B, C, D, E, F The patient's ability to adapt to interventions such as are the insertion should be noted when the intervention is performed. The date and time of insertion are important data. IV site need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used often the brand name is given as well as all specifics such as needle or cannula length, gauge and material. It is necessary to describe the dressing applied and the vein should be noted.

The registered nurse is training a student nurse on the use of peripheral vascular access devices. The RN states that one patient is receiving IV anabiotic's to treat a lower respiratory infection, but because he has severe lower extremity edema, they are administering the antibiotic's intermittently. Which statement by the nurse indicates an understanding of peripheral VADs?

B. Peripheral VADs that are used intermittently should be converted into an intermittent IV lock or saline lock. This is often done using a short peripheral catheter.

Which drug is usually administered to a patient after orthopedic surgery to prevent deep vein thrombosis?

B. The patient who has undergone orthopedic surgery is at high risk of developing deep vein thrombosis. ENOXAPARIN is a low molecular weight heparin that prevents blood clot formation and reduces the risk of deep vein thrombosis.

The nurse is preparing to administer an infusion of heparin using a smart pump. After programming the pond and attaching the ivy to the client, what action by the nurse is most important?

B. Using a smart infusion pump does not relieve the nearest of the responsibility of ensuring that the rate is correct pumps can malfunction or can be programmed incorrectly, and concentrations of solution can change and differ from the dumps drug library. The nurse must hand calculate the rate before starting the infusion, then ensure that the pump is plugged into an electrical source.

When a client has an arterial blood pH of 7.48, which buffer action would bring the pH back to normal?

Buffers can act as an acid (releasing a hydrogen ion) or as a base (absorbing a hydrogen ion) to assist in keeping the pH and hydrogen ion concentration of body fluids within normal range. In arterial pH of 7.48 indicates a deficiency of hydrogen ions. This situation would cause buffers to act like acid's and release hydrogen ions into blood.

A nurse is caring for four patients. Which one should the nurse see first?

C angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this patient first to prevent falling if the client decides to get up without assistance.

You have 2000 ML D5W being infused for 24 hours. How many ML per hour will be infused?

C. 83 TV/TT= 2000/24

The registered nurse is evaluating a student nurse performing a physical assessment on a patient with atherosclerosis. Which action of the student nurse needs correction?

C. The blood pressure should be measured in both arms for accurate results. The nurse should to check capillary filling because abnormal values may indicate poor circulation.

A patient reports calf muscle pain after walking about one or two blocks. The nurse finds pale ulcers with even edges and little granulation tissue at the end of the toes, atrophy of skin, cold foot, and absence of pulses. What should the nurse interpret from these findings?

Claudication, Or calf muscle pain, after walking about 1 to 2 blocks, a pale ulcer with even edges and little granulation tissue at the end of the toes, atrophy of skin, a cold foot, and the absence of pulses are all symptoms of arterial ulcers.

The nurse is assessing a client understanding of his hypertension therapy. What client statement indicates a need for further teaching?

Compliance with antihypertensive therapy is difficult for two reasons. First often clients have no distressing symptoms associated with hypertension and may not believe they have a problem. Second many clients believe that once blood pressure is brought back into normal range, they are cured and no longer need to take medication.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are PH- 7.53, PaO2- 72mmHg, paCO2- 32mmHg, and HCO3- 28mEq/L. Which conclusion about the client should the nurse make?

D The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis.

A nurse is auscultating a clients heart sounds. In which area should the nurse place their stethoscope to hear the mitral valve?

D This is the mitral area at the fifth intercostal space at the left midclavicular line. (Apex)

The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess first?

D older adults are more prone to fluid overload and resulting congestive heart failure. Because this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be assessed.

To determine the status of the clients carotid pulse, the nurse should palpate:

D. The carotid artery is located along the anterior edge of the STERNOCLEIDOMASTO ID muscle at the level of the lower margin of the thyroid cartilage.

Which IV order does the nurse question?

D. To be complete IV orders for infusion fluids should specify the rate of infusion. This order does not specify the rate of infusion and is not considered complete.

The nurse is recovering a client with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate post procedural period?

For this procedure, a catheter advanced through a cannula inserted through the femoral artery. The nurse must monitor The client for bleeding at the puncture site.

Order: Keflin 2g IVPB (piggyback) over 30 min. The Keflin is placed in 100 mL fluid after its dissolved. The drip factor is 15 ft/mL. At what rate in get/min should the IV be regulated?

Gtt/min= 100ml•15gtt/min/30 min

A student nurse notes that a patient who has just been admitted to the hospital has a hemodialysis catheter. The physician asked the registered nurse who is supervising the student nurse to draw some blood and start an IV antibiotic. Which statement by the student nurse indicates that additional teaching is needed about the use of hemodialysis catheters?

Hemodialysis catheters should not be used for administration of drugs or fluids except in an emergency. Therefore the student statement that they can use the hemodialysis catheter to draw blood and inject drugs is incorrect.

A client is furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition?

Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. At 2.9 potassium is too low, and this could lead to neurologic manifestations.

A client has acidosis. Which laboratory finding is of greatest concern to the nurse?

In the client with acidosis intracellular buffering leads to entry of hydrogen ions into cells, and in return potassium leaves the cell. This leads to elevated serum potassium levels. Many severe problems with acidosis are due to the accompanying hyperkalemia.

What is the pharmacokinetics of drugs such as furosemide or torsemide?

Loop diuretic

A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?

Mis-use and overuse of diuretics, especially high ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia an older adults and in clients with eating disorders.

One month after an ENDARTERECTOMY the surgeon instruct the client to take CLOPIDoGREL (Plavix) 75 mg once a day. The nurse evaluate that the reason for taking this drug is understood when the client says, "it will":

Plavix interferes with platelet aggregation, which impedes the formation of thrombi.

Ordered: 1500mL of ringers lactate solution to be infused for 12 hr. Below is the IV tubing (15 get/mL)

Step 1: TV/TT= 1500/12 =125 mL/hr Step 2: ((1/15)/(60/4)*(125/1))= (125/4)= 31.25 or 31 drops per minute

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous". What action by the nurse is best?

The first step is to access the reason behind the clients fear, which may be related to the experience of someone the client knows who took the warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful.

The nurse is caring for a client with BUERGER's disease. What client education does the nurse provide to minimize disease progression?

The greatest risk factor for the development and progression of BUERGER's disease is cigarette smoking. To prevent the progression of BUERGER's disease, complete abstinence from tobacco in all forms is essential.

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 MMHG, PaO2 of 80 MMHG, and HCO3 of 27. The nurse interprets that the client has which acid-base disturbance?

The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45. In respiratory acidosis the pH is low and the PaCO2 is elevated.

A client has an arterial blood gas pH of 7.48 how does the nurse interpret this clients acid-base status?

The pH is the negative log of the hydrogen ion concentration. The normal pH of arterial blood ranges between 7.35 and 7.45. A pH of 7.48 indicates a decrease in the hydrogen ion concentration (alkalosis).

The nurse is caring for a patient who is receiving heparin therapy for a venous thromboembolism. The clients activated partial thromboplastin time before heparin therapy was 30 seconds. Which APTT result indicates that anticoagulation is adequate at this time?

Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value