A patient is prescribed an anticoagulant for the prevention of venous thromboembolism (VTE). Which laboratory parameter should the nurse monitor closely during anticoagulant therapy?

Correct Answer: B

Rationale: The nurse should monitor the International Normalized Ratio (INR) closely during anticoagulant therapy for the prevention of VTE. The INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy, such as warfarin. Maintaining the INR within the target therapeutic range is crucial to prevent both excessive bleeding due to over-anticoagulation and clotting events due to under-anticoagulation. Close monitoring of the INR helps healthcare providers adjust the anticoagulant dosage as needed to ensure optimal therapeutic outcomes and minimize risks. Platelet count, serum sodium levels, and blood urea nitrogen (BUN) are important laboratory parameters to monitor for other medical conditions but are not specific to anticoagulant therapy.

Correct Answer: C

Rationale: The correct response is "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep." This phenomenon occurs due to gravity when a woman lies down, and the blood tends to pool at the top of the vagina. When she first arises from bed, the pooled blood is released, resulting in a gush of blood. This is a normal physiological process and not typically a cause for concern.

Correct Answer: D

Rationale: It is essential for the nurse to instruct the patient to "Report any unusual bleeding or bruising to your healthcare provider." Warfarin is a medication that works by decreasing the clotting ability of the blood. This can increase the risk of bleeding, so it is important for the patient to be vigilant for any signs of abnormal bleeding. Prompt reporting of any unusual bleeding or bruising allows healthcare providers to adjust the dosage of warfarin to maintain a balance between preventing blood clots and minimizing the risk of bleeding complications. This instruction emphasizes the importance of close monitoring and communication with healthcare providers while on warfarin therapy.

Correct Answer: C

Rationale: Battery occurs when there is an intentional touching of another person without their consent. In this case, the nurse began cardiopulintary resuscitation on a client who had requested a "Do Not Resuscitate" (DNR) order, which means the client did not consent to the resuscitation. This action can be considered as battery because the client's wishes were not respected, and the nurse proceeded with a medical intervention against those wishes, leading to harm and potential legal consequences. This is different from assault, which involves a threat of force, and from defamation and fraud, which are not applicable to this situation.

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: C

Rationale: The presentation described is consistent with fungal keratitis. Fungal keratitis typically presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. The filamentous opacities seen on slit-lamp examination are characteristic of fungal hyphae extending from the corneal lesion. This condition is often associated with risk factors such as trauma with vegetable matter, contact lens wear, or topical corticosteroid use. Prompt diagnosis and treatment with antifungal medications are essential to prevent complications and preserve vision.

Correct Answer: B

Rationale: The type of pregnancy test is not a factor that should be considered by the nurse or the pregnant woman in interpreting the results of a pregnancy test. Factors such as the last menstrual period, previous pregnancy history, and menstrual cycle length play a crucial role in determining the reliability and accuracy of the pregnancy test results.

Correct Answer: A

Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.