A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse?
a. Potassium (K+), 4.2 mEq/L
b. International normalized ratio (INR), 5.1
c. Prothrombin time (PT), 13.4 seconds
d. Hemoglobin (Hg), 16 g/dL
B
Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.
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The federal government requires the use of a specific standardized documentation tool for home nursing care. Which information must a home nurse add to the approved documentation tool?
a. Activity c. Functional b. Vital signs d. Demographic
The patient is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the patient asks for another. The best response from the nurse is:
1. "I'll get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I'll bring you an extra so that you can change it when you are ready."
The client is a male who states his wife complains that his snoring awakens her at night. The spouse is present. To obtain further data, the nurse asks the spouse what?
A) "How loud is his snoring?" B) "Is there silence after snoring which then is followed with a snort?" C) "How long does he snore each night?" D) "How often are you awakened at night due to his loud snoring?"
Which condition should the nurse be concerned about for a client prescribed fluticasone (Flonase)?
A. Diabetes mellitus B. Pregnancy C. Glaucoma D. Hypertension