Medical Surgical Nurse Certification

A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?a. Increase the heparin infusion flow rate by 2 mL/hrb. continue to monitor the heparin infusion as prescribedc. request a prothrombin timed. stop the heparin infusion - Answer- d A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching?a. "you may no longer be able to feel chest pain."b. "your level of activity tolerance will not change."c. "after 6 months, you will no longer need to restrict your sodium intake."d. "you will be able to stop taking immunosuppressants after 12 months." - Answer- a A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?A. confusionB. friction rubC. hypertensionD. dry skin - Answer- a A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?A. administering IV morphine sulfateB. administering oxygen at 2 :/min via nasal cannulaC. helping the client to the bedside commodeD. assisting with thrombolytic therapy - Answer- d A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?A. ventricular depolarizationB. Guillain-Barre syndromC. myelodysplastic syndromeD. Valvular disease - Answer- D A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?A. obtain blood samples for laboratory testingB. Tell the client to report vision changesC. Place the head of the bed at 45 degreesD. initiate an IV - Answer- C a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for and report which of the following findings to the provider immediately?a. slurred speechb. irregular pulsec. dependent edemad. persistent fatigue - Answer- a A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?a. inc abdominal girthb. weak peripheral pulsesc. jugular vein distentiond. dependent edema - Answer- b a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin