Assisting with thrombolytic therapy
The nurse should recognize that major surgery within
the previous 3 weeks is a contraindication for
thrombolytic therapy.
A nurse in an emergency
department is caring for a
client who had an anterior
myocardial infarction. The
client's history reveals she
is 1 week postoperative
following an open
cholecystectomy. The
nurse should recognize
that which of the following
interventions is
contraindicated?
-Administering IV
morphine sulfate
-Administering oxygen at
2 L/min via nasal cannula
-Helping the client to the
bedside commode
-Assisting with
thrombolytic therapy
, Elevate the head of the client's bed.
The greatest risk to this client is organ injury due to
severe hypertension. Therefore, the first action the
A nurse in an emergency nurse should take is to elevate the head of the client's
department is caring for a bed to reduce blood pressure and promote
client who has a blood oxygenation.
pressure of 254/139
mmHg. The nurses
recognizes that the client
is in a hypertensive crisis.
Which of the following
actions should the nurse
take first?
-Initiate seizure
precautions
-Tell the client to report
vision changes
-Elevate the head of the
client's bed
-Start a peripheral IV
Confusion
Bradydysrhythmia can cause decreased systemic
A nurse in an emergency perfusion, which can lead to confusion.
room is assessing a client
who has a
bradydysrhythmia. Which
of the following findings
should the nurse monitor
for?
-Confusion
-Friction rub
-Hypertension
-Dry skin
, Inquire about the presence or absence of claudication
Clients who have arterial ulcers experience
claudication, but those who have venous ulcers do
not.
A nurse is admitting a
client who has a leg ulcer
and a history of diabetes
mellitus. The nurse should
use which of the following
focused assessments to
help differentiate between
an arterial ulcer and a
venous stasis ulcer?
-Explore the client's family
history of peripheral
vascular disease
-Note the presence or
absence of pain at the
ulcer site
-Inquire about the
presence or absence of
claudication
-Ask if the client has had a
recent infection
INR 2.0
The nurse should identify that an INR of 2.0 is within
the desired reference range of 2.0 to 3.0 for a client
A nurse is assessing a who has a deep-vein thrombosis and is receiving
client who has a history of warfarin to reduce the risk of new clot formation and a
deep-vein thrombosis and stroke.
is receiving warfarin. The
nurse should identify that
which of the following
findings indicates the
medication is effective?
-Hemoglobin 14 g/dL
-Minimal bruising of
extremities
-Decreased blood
pressure
-INR 2.0
The nurse should recognize that major surgery within
the previous 3 weeks is a contraindication for
thrombolytic therapy.
A nurse in an emergency
department is caring for a
client who had an anterior
myocardial infarction. The
client's history reveals she
is 1 week postoperative
following an open
cholecystectomy. The
nurse should recognize
that which of the following
interventions is
contraindicated?
-Administering IV
morphine sulfate
-Administering oxygen at
2 L/min via nasal cannula
-Helping the client to the
bedside commode
-Assisting with
thrombolytic therapy
, Elevate the head of the client's bed.
The greatest risk to this client is organ injury due to
severe hypertension. Therefore, the first action the
A nurse in an emergency nurse should take is to elevate the head of the client's
department is caring for a bed to reduce blood pressure and promote
client who has a blood oxygenation.
pressure of 254/139
mmHg. The nurses
recognizes that the client
is in a hypertensive crisis.
Which of the following
actions should the nurse
take first?
-Initiate seizure
precautions
-Tell the client to report
vision changes
-Elevate the head of the
client's bed
-Start a peripheral IV
Confusion
Bradydysrhythmia can cause decreased systemic
A nurse in an emergency perfusion, which can lead to confusion.
room is assessing a client
who has a
bradydysrhythmia. Which
of the following findings
should the nurse monitor
for?
-Confusion
-Friction rub
-Hypertension
-Dry skin
, Inquire about the presence or absence of claudication
Clients who have arterial ulcers experience
claudication, but those who have venous ulcers do
not.
A nurse is admitting a
client who has a leg ulcer
and a history of diabetes
mellitus. The nurse should
use which of the following
focused assessments to
help differentiate between
an arterial ulcer and a
venous stasis ulcer?
-Explore the client's family
history of peripheral
vascular disease
-Note the presence or
absence of pain at the
ulcer site
-Inquire about the
presence or absence of
claudication
-Ask if the client has had a
recent infection
INR 2.0
The nurse should identify that an INR of 2.0 is within
the desired reference range of 2.0 to 3.0 for a client
A nurse is assessing a who has a deep-vein thrombosis and is receiving
client who has a history of warfarin to reduce the risk of new clot formation and a
deep-vein thrombosis and stroke.
is receiving warfarin. The
nurse should identify that
which of the following
findings indicates the
medication is effective?
-Hemoglobin 14 g/dL
-Minimal bruising of
extremities
-Decreased blood
pressure
-INR 2.0
