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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 labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first

Correct Answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.

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

Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?

Correct Answer: A

Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.

Question 5 of 5

The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?

Correct Answer: C

Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and
A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin
A), wheat roll (carbohydrates), and orange (vitamin
C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.

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