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Question 1 of 5

A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.

Question 2 of 5

A client with heart failure has a left ventricular ejection fraction of 38%. When educating the client about managing the condition, which of the following advice should the nurse include? Select all that apply.

Correct Answer: A,B,D

Rationale: Rest periods (
A), avoiding strenuous activities (
B), and stopping smoking (
D) manage heart failure. All exercise (
C) is not stopped; moderate activity is encouraged. Alcohol should be minimal, not 2-3 drinks (E).

Question 3 of 5

A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia, the nurse should have which medication available?

Correct Answer: D

Rationale: Epinephrine is used to treat hypotension from epidural anesthesia by increasing blood pressure through vasoconstriction and cardiac stimulation.

Question 4 of 5

Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?

Correct Answer: A

Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.

Question 5 of 5

The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?

Correct Answer: A

Rationale: Medication errors require notifying the supervisor and completing an incident report (
A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (
B) is unethical, assuming acetaminophen is benign (
C) is unsafe, and documenting the error in the client's record (
D) is inappropriate.

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