A nurse is caring for a client who is prescribed warfarin. Which of the following laboratory tests should the nurse review to evaluate the therapeutic effect of this medication?

Correct Answer: B

Rationale: The correct answer is B: INR. The International Normalized Ratio (INR) is the most reliable test for evaluating the therapeutic effects of warfarin therapy. INR measures the clotting ability of the blood and helps determine if the dosage of warfarin is within the therapeutic range. Choice A, aPTT, is not typically used to monitor the effects of warfarin. Choice C, Serum glucose, and choice D, Bilirubin, are not relevant to monitoring the therapeutic effect of warfarin.

Correct Answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

Correct Answer: D

Rationale: The correct answer is D: Hearing acuity. Gentamicin is known to be ototoxic, which means it can cause damage to the auditory system leading to hearing loss. Monitoring hearing acuity is crucial to detect early signs of hearing impairment. Monitoring urinary output (choice A) is important for assessing kidney function but is not directly related to gentamicin's adverse effects. Monitoring serum glucose (choice B) and respiratory rate (choice C) are not specifically associated with gentamicin therapy.

Correct Answer: B

Rationale: The correct instruction for administering insulin is to rotate injection sites to prevent lipodystrophy, a common complication of insulin therapy. Injecting into the deltoid muscle (Choice A) is not recommended for insulin injections. Massaging the site after injection (Choice C) is not necessary and can potentially increase the risk of lipodystrophy. Using the same site for each injection (Choice D) can lead to localized tissue damage and absorption irregularities, making it an incorrect choice.

Correct Answer: A

Rationale: In this question, the correct answer is "A) Cough." When a client is prescribed lisinopril, an ACE inhibitor commonly used to treat hypertension, they may experience a persistent dry cough as a side effect. This cough is a result of the drug's action on bradykinin metabolism in the lungs. It is important for the nurse to monitor for this side effect as it can be bothersome to the patient and may necessitate a change in medication. Options B, C, and D are incorrect. Weight gain is not a common side effect of lisinopril. Dry mouth is also not typically associated with lisinopril use. Hyperglycemia is not a common side effect of lisinopril as it does not affect blood glucose levels like some other antihypertensive medications. In an educational context, understanding the side effects of common medications like lisinopril is crucial for nurses to provide safe and effective care. By knowing the potential side effects, nurses can monitor patients appropriately, educate them on what to expect, and intervene promptly if adverse reactions occur. This knowledge enhances patient safety and promotes positive health outcomes.