A nurse is caring for a client with a history of overdosage of aspirin. The nurse suspects which of the following can be an early sign of aspirin toxicity?

Correct Answer: D

Rationale: Tinnitus, or ringing in the ears, can be an early sign of aspirin toxicity. Aspirin poisoning can lead to salicylate toxicity, which can manifest with various symptoms including tinnitus, along with hyperventilation, nausea, vomiting, and metabolic acidosis. Monitoring for tinnitus is crucial as an early indicator of potential aspirin overdose in clients. Unsteady gait, drowsiness, and confusion are also symptoms of aspirin toxicity but typically develop after tinnitus in the progression of toxicity.

Correct Answer: B

Rationale: Heparin anticoagulates, monitored by aPTT (therapeutic: 60-80 seconds). An aPTT of 90 seconds indicates over-anticoagulation, risking bleeding, needing immediate action (e.g., stop infusion). Bruising and redness are minor. Platelets of 150,000 are normal. Prolonged aPTT aligns with heparin's effect, critical in therapy where bleeding is a threat, making B the finding requiring swift response.

Correct Answer: A

Rationale: Autonomy refers to the patient's right to make informed decisions about their own healthcare. By expressing a desire to avoid life-prolonging measures and requesting a living will, the patient is exercising his autonomy. Beneficence involves acting in the patient's best interest, justice refers to fairness in healthcare, and veracity involves truth-telling. The patient's statements align most closely with the principle of autonomy, as he is asserting his right to control his medical care.

Correct Answer: D

Rationale: A 25 percent albumin solution contains 25 grams of albumin per 100 milliliters. To administer 1 gram of albumin, the nurse would calculate the volume as follows: 1 gram ÷ 25 grams/100 milliliters = 4 milliliters. Therefore, the nurse will administer 4 milliliters of the 25 percent albumin solution to deliver the ordered dose of 1 gram. Using the entire vial or not using the product at all would be incorrect.

Correct Answer: A

Rationale: Warfarin is an anticoagulant medication commonly used to prevent blood clots. One of the most severe adverse effects of warfarin is the risk of bleeding. This can occur in various parts of the body, such as the gastrointestinal tract, brain, or other organs. Bleeding complications can range from minor bruising to life-threatening hemorrhages, especially if warfarin levels are not properly monitored. Patients taking warfarin should be closely monitored for signs of bleeding, and their medication dosages should be adjusted as needed to maintain a balance between preventing clotting and avoiding excessive bleeding.