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Questions 164

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Extract:

Laboratory results
Hematocrit
Male: 42%–52%
(0.42-0.52)

Female: 37%–47%
(0.37–0.47) 30%
(0.30)
Activated PTT
Baseline: 30–40 sec 110 sec
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 80,000/mm3
(80 x 109/L)
PT
11–12.5 sec 11 sec


Question 1 of 5

The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?

Correct Answer: A

Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial
thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40
seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side
effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina
bleeds (Option 1).
(Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic
anemia, a hematocrit of 30% (0.30) may be an expected finding.
(Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver
cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs
with a platelet count >50,000 mm* (50 x 10%/L).
(Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be
concerning.

Extract:


Question 2 of 5

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?

Correct Answer: D

Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (
D) is standard to guide dosing adjustments. A new IV line (
A) is unnecessary unless the current line is compromised. Antiemetics (
B) are not routinely needed. Infusion over 60 minutes (
C) is typical to prevent red man syndrome, not 30 minutes.

Question 3 of 5

A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

Correct Answer: C

Rationale: A rash (
C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (
A), urination (
B), and nausea (
D) are less urgent.

Question 4 of 5

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?

Correct Answer: A

Rationale: Asymmetrical chest expansion and decreased breath sounds (
A) suggest pneumothorax, a serious post-thoracentesis complication. Hypotension (
B), pain (
C), and mild tachypnea (
D) are less urgent or expected.

Question 5 of 5

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Allowing food refusal (
A) respects autonomy, assessing pain/nausea (
B) addresses barriers to eating, shared mealtimes (
D) provide comfort, and oral care (E) improves appetite. Meal planning (
C) may overwhelm a cachectic client.

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