The nurse assesses blood in the urine of the 73-year-old patient receiving warfarin (Coumadin) this morning. What actions will the nurse take? (Select all that apply.)
A) Assess prothrombin time (PT).
B) Assess international normalized ratio (INR).
C) Expect to administer protamine sulfate.
D) Expect to administer vitamin K.
E) Assess partial thromboplastin time (PTT).
A, B, D
Feedback:
Vitamin K is the antidote for warfarin. PT and INR are used to assess therapeutic levels of warfarin. PTT is used to assess therapeutic levels of heparin. Protamine sulfate is given as an antidote for heparin.
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The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching provided to these parents has been effective?
A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."
Which is the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating hormone?
a. Hypoglycemia and hyperkalemia b. Irritability and insomnia c. Increased urine output d. Darkening of the skin
A clinic patient comes to an appointment carrying a baby. The nurse notes abrasions on the baby's thighs and determines that skin scraping has been used. In an effort to use cultural negotiation, the nurse should
a. encourage using less pressure during scraping to prevent abrasions and infections. b. show the parent how to use moxibustion rather than skin scraping. c. explain that skin scraping does not effectively treat illness. d. caution that the scraped skin can become infected.
An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness?
A. 100 mL B. 250 mL C. 400 mL D. 800 mL