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NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?
A. Triiodothyronine
Is a thyroid hormone and is not directly related to warfarin therapy.
B. Blood urea nitrogen
Is a measure of kidney function and is also not directly related to warfarin therapy.
C. Arterial blood gases
Is a measure of oxygen and carbon dioxide levels in the blood and is not related to warfarin therapy.
D. Prothrombin time
Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. Therefore, it is important to monitor the client's clotting ability to ensure that the medication is working properly and not causing any adverse effects. The laboratory test that is used to monitor warfarin therapy is the prothrombin time (PT), which measures the time it takes for the blood to clot. The nurse should monitor the client's PT regularly and adjust the dosage of warfarin as necessary to maintain the therapeutic range.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Prothrombin time.
Explanation:
When a client is prescribed warfarin, monitoring the prothrombin time (PT) and the International Normalized Ratio (INR) is crucial. Warfarin is an anticoagulant medication that affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time and INR helps determine the client's blood's ability to clot and the appropriate dosage of warfarin to maintain the desired therapeutic range.
Option a (Triiodothyronine) is a thyroid hormone and is not directly related to warfarin therapy.
Option b (Blood urea nitrogen) is a measure of kidney function and is also not directly related to warfarin therapy.
Option c (Arterial blood gases) is a measure of oxygen and carbon dioxide levels in the blood and is not related to warfarin therapy.
Similar Questions
A nurse is assisting with the care of a client.
Complete the following sentence.
After notifying the provider, the nurse should first and then . (Separate your answers with a comma ',')
Full Explanation
The client's symptoms are concerning for angina or a possible myocardial infarction (heart atack) and require immediate intervention. Nitroglycerin is a medication that can help relieve chest pain associated with cardiac events by dilating blood vessels and reducing the workload on the heart.
Therefore, the nurse should administer nitroglycerin as ordered by the provider. After administering nitroglycerin, the nurse should obtain an ECG to assess for any changes in cardiac rhythm or evidence of ischemia (lack of blood flow to the heart muscle).
The ECG can provide important diagnostic information and guide further treatment decisions.
A nurse is assisting with the care of a client.
Laboratory Results
Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in).
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
A. Inform the client that an advance directive discontinues further care.
An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.
B. Initiate a power of atorney for health care document.
While nurses can provide information and support the client in understanding the importance of having a power of attorney for healthcare, initiating such documents is typically not within the scope of nursing practice. This task usually requires legal guidance and formalities that go beyond nursing responsibilities.
C. Document that the provider discussed do-not-resuscitate status with the client.
Accurate documentation is crucial in healthcare. If a provider discusses do-not-resuscitate (DNR) status with a client, it must be documented in the client's medical record to ensure that all healthcare team members are aware of the client’s wishes.
D. Provide the client with written information about advance directives.
It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.
E. Communicate advance directives status via the medical record and shift report.
The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers.
The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.
Full Explanation
c, d, e, and f.
a. An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.
b. While nurses can provide information and support the client in understanding the importance of having a power of attorney for healthcare, initiating such documents is typically not within the scope of nursing practice. This task usually requires legal guidance and formalities that go beyond nursing responsibilities.
c. Accurate documentation is crucial in healthcare. If a provider discusses do-not-resuscitate (DNR) status with a client, it must be documented in the client's medical record to ensure that all healthcare team members are aware of the client’s wishes.
d. Provide the client with writen information about advance directives: It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.
e. Communicate advance directives status via the medical record and shift report: The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.
f. Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.
A nurse is assisting with the care of a client in a medical-surgical unit.
Vital Signs
05:00
Temperature 36.6 C (97.9 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 160/98 mm Hg
Oxygen saturation 96% on oxygen 2 L/min via nasal cannula
14:00
Temperature 36.8 C (98.3 F)
Heart rate 90/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 97% on oxygen 2 L/min via nasal cannula
Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.
A. Encourage the client to drink 3,000 mL of fluid daily.
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹.
B. Change the indwelling urinary catheter tubing every 3 days.
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C. Place the drainage bag on the bed when transporting the client.
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D. Empty the drainage bag when it is half-full.
The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
E. Review the need for the indwelling urinary catheter daily.
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F. Use soap and water to provide perineal care.
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Full Explanation
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.
