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Questions 148

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Question 1 of 5

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.

Question 2 of 5

A client has ataxia following a cerebral vascular accident. The nurse should:

Correct Answer: A

Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.

Question 3 of 5

The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?

Correct Answer: B

Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.

Question 4 of 5

A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a 2-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?

Correct Answer: C

Rationale: The frontal lobe is involved in sensory processing and cognition, so failure to recognize touch (agnosia) is consistent with frontal lobe injury.

Question 5 of 5

A.ls with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

Correct Answer: D

Rationale: Leucovorin calcium is given as a rescue therapy to reverse the toxic effects of trimetrexate, protecting healthy cells from damage.

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