The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk
for bleeding and the nurse should notify the HCP immediately.
A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At
11:00 am, the child has a temperature of 98.2⁰ F (36.7⁰ C). At 1:00 pm, the child's
parent reports to the nurse that the child feels very warm to touch. What should the
nurse do first?
1Reassure the parent that this is normal.
2Take the child's temperature.
3Offer the child cold oral fluids.
4Administer prescribed acetaminophen.
- 2
The nurse is caring for a 60-year-old female client scheduled for abdominal surgery.
Which factor in the client's history indicates that the client is at an increased risk for
deep vein thrombosis (DVT) in the postoperative period?
1Past hypersensitivity to heparin
2Family history of uterine cancer
3Estrogen replacement therapy for the past three years
4History of acute hepatitis A
- 3
The estrogen in hormone replacement therapy (and in birth control pills) can increase
clotting factors in the blood, increasing the risk for development of a DVT.
The nurse is caring for a client receiving mechanical ventilation. The nurse understands
which are the possible causes for a high-pressure alarm? (Select all that apply.)
-
Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the
ventilator, creating high pressure in the ventilator circuit and setting off the high-
pressure alarm.
The nurse is reviewing the medical record of a client on the medical surgical unit and
notes a positive result of the stool for occult blood (OB) test. The nurse recognizes
which risk factors for this result? (Select all that apply.)
- Drugs that can cause GI
bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can
cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors
that may cause a false positive result include bleeding gums following a dental
procedure and the ingestion of red meats within three days before testing because red
meats contain animal hemoglobin.
A client is scheduled for a computerized tomography (CT) scan of the abdomen with
contrast. What action should the nurse take before sending the client to the imaging
department?
1Insert a temporary urinary catheter.
2Confirm that a signed consent is in the chart.
3Keep the client on bedrest.
4Hold all of the client's medications.
- 2
