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Questions 149

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Question 1 of 5

The nurse is preparing to administer heparin to a client with a deep vein thrombosis. Which of the following laboratory values should the nurse check before administering the dose?

Correct Answer: B

Rationale: heparin’s therapeutic effect is monitored by aPTT, which should be 1.5–2 times the control value

Question 2 of 5

The nurse reviews a 21-year-old female's bloodwork from the lab. Which result would be charted as an abnormal finding?

Correct Answer: C

Rationale: WBC 15.6 (normal 4.5-11.0 x 10³/μL) is elevated, indicating possible infection or inflammation. Platelets (150-450 x 10³/μL) are slightly low, RBC (4.2-5.4 million/μL) and hematocrit (36-46%) are normal for females.

Question 3 of 5

The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?

Correct Answer: A

Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency

Question 4 of 5

While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:

Correct Answer: A

Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.

Question 5 of 5

A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?

Correct Answer: A

Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.

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