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NEW QUESTION 30
A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the:
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) PT evaluates adequacy of extrinsic clotting pathway. Adequacy of warfarin therapy is monitored by PT.
(B) PTT evaluates adequacy of intrinsic clotting pathway. Adequacy of heparin therapy is monitored by PTT. (C) There is no such laboratory test. (D) Fibrin split products indicate fibrinolysis. This is a screening test for disseminated intravascular coagulation. Heparin therapy may increase fibrin split products.
NEW QUESTION 31
A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Lochia rubra is bloody with clots and occurs 1-3 days postpartum. (B) There is no such term as lochia rosa. (C) Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. (D) Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
NEW QUESTION 32
A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby's arms. The nurse should respond:
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the client medical terms that may be useful in understanding other healthcare personnel. (B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation. (C) This response correctly identifies this neonatal variation and helps the client to understand medical terms as well as the characteristics of her newborn. (D) Blocked sebaceous glands produce milia, particularly present on the nose.
NEW QUESTION 33
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
Answer: B
Explanation:
(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
NEW QUESTION 34
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-
9 breaths/min.
NEW QUESTION 35
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