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Questions 148

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Question 1 of 5

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified

Question 2 of 5

The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?

Correct Answer: C

Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.

Question 3 of 5

The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

Correct Answer: A

Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.

Question 4 of 5

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

Correct Answer: C

Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.

Question 5 of 5

A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:

Correct Answer: B

Rationale: Adequate hydration is critical to prevent cisplatin-induced nephrotoxicity by promoting renal excretion of the drug.

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