ATI Comprehensive B

ATI Comprehensive B Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? - ANSWER Ask another nurse to witness the disposal of the new patch. Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 - ANSWER Withhold the heparin infusion A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina - ANSWER Floating dark spots infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider - ANSWER Irritability when being held. signifies increased ICP Assessing a newborn heart rate follow actions the nurse should take - ANSWER Auscultate the apical pulse and count beats for at least 1 min.