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B) Prothrombin (PT) - (ANSWER)A nurse is caring for a client who is prescribed warfarin
therapy for an artificial heart valve. Which of the following laboratory values should the nurse
monitor for a therapeutic effect of warfarin?
A) Hemoglobin (Hgb)
B) Prothrombin (PT)
C) Bleeding time
D) Activated partial thromboplastin time (aPTT)
B) The client's bladder becomes distended. - (ANSWER)A nurse is caring for a client who has a
T-4 spinal cord injury. Which of the following client findings should the nurse identify as an
indication the client is at risk for experiencing autonomic dysreflexia?
A) The client states having a severe headache.
B) The client's bladder becomes distended.
C) The client's blood pressure becomes elevated.
D) The client states having nasal congestion.
A) Impaired tissue perfusion - (ANSWER)While performing an admission assessment for a
client, the nurse notes that the client has varicose veins with ulcerations and lower extremity
edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should
the nurse identify as being the priority in the client's care?
A) Impaired tissue perfusion
B) Alteration in body image
C) Alteration in activity tolerance
D) Impaired Skin integrity
D) "I will take my medications at the first time of an attack." - (ANSWER)A nurse is instructing
a client who has a new diagnosis of Raynaud's disease about preventing the onset of
manifestations. Which of the following client statements should indicate to the nurse the need for
additional teaching?
, A) "I will wear gloves when removing food from the freezer."
B) "I will try to anticipate and avoid stressful situations when possible."
C) "I will complete the smoking cessation program I started."
D) "I will take my medications at the first time of an attack."
A) "I have started taking ginger root to treat my joint stiffness." - (ANSWER)A nurse is teaching
a client who takes warfarin daily. Which of the following statements by the client indicates a
need for further teaching?
A) "I have started taking ginger root to treat my joint stiffness."
B) "I take this medication at the same time each day."
C) "I eat a green salad every night with dinner."
D) "I had my INR checked three weeks ago."
D) "I feel nauseated and have no appetite." - (ANSWER)A nurse is caring for a client who has
heart failure and a prescription for digoxin. Which of the following statements by the client
indicates an adverse effect of the medication?
A) "I can walk a mile a day."
B) "I've had a backache for several days."
C) "I am urinating more frequently."
D) "I feel nauseated and have no appetite."
C) Perform neurovascular checks of the extremities. - (ANSWER)A nurse is caring for a client
who is postoperative following an open reduction and internal fixation of a fracture femur.
Which of the following actions is the most important for the nurse to complete in the
postoperative period?
A) Medicate the client for pain.
B) Instruct the client on the use of crutches.
C) Perform neurovascular checks of the extremities.
D) Direct the client to perform exercises of the ankle and toes.