•Hematuria is a sign of anticoagulation and heparin overdose. The physician should be notified to determine the plan of action.
•Protamine is the antidote for heparin overdose. Since the heparin infusion is used to treat a pulmonary embolism, protamine should not be given unless confirmed by the physician.
•A PTT should be checked, but only after the immediate threat is dealt with.
The nurse is caring for a patient with pleurisy. When the nurse auscultates the patient's lungs, a friction rub is heard. This friction rub is the result of:
A patient has been taking antibiotics for 3 days to treat pyelonephritis. Which of the following findings requires the nurse's immediate attention?
A patient suspected of diverticulitis is admitted to the hospital for evaluation and treatment. The nurse explains to a student nurse that the classic triad of signs and symptoms are:
A patient recently diagnosed with psoriasis is being instructed on the precipitating factors associated with this disease. Which of the following should the nurse include?
A patient with Raynaud's disease is admitted to the hospital with cyanotic fingers and extreme pain. To find a cause for the acute attack, the nurse asks if the symptoms occur with:
A patient is being examined for a suspected peptic ulcer. The nurse knows that what symptom indicates a duodenal ulcer rather than a gastric ulcer?
A nurse is performing a neurological check on a patient who is
A nurse received an order to initiate early ambulation with a patient post appendectomy. The nurse recognizes this activity to be helpful in preventing possible complications associated with prolonged bed rest. To assist her to start walking after surgery, the nurse will:
A patient is admitted to the hospital with a myocardial infarction (MI). When assessing the patient for pain, the nurse is most likely to observe referred pain in what location?
An adolescent with leukemia asked the nurse what carcinogens are. The nurse correctly answers the patient by explaining that carcinogens are factors associated with cancer causation such as:
A patient with emphysema is receiving discharge instructions regarding home oxygen use via nasal cannula. Which of the following statements should the nurse include?
A patient with progressive multiple myeloma is being cared for in a hospice house. The nurse should include which of the following in the plan of care?
A patient was diagnosed with Parkinson’s disease. What intervention should be prioritized in the nursing care plan?
The nurse is providing ostomy care for a patient after a colectomy. The patient is complaining of the foul odor coming from the ostomy. The nurse instructs the patient to consume more odor eliminating foods, such as:
A patient with a nasogastric tube (NG) is complaining of abdominal pain and feeling full. The patient underwent a colon resection 2 days ago and states that the discomfort has been progressing. What should the nurse do first?
A 25-year-old patient diagnosed with leukemia underwent a bone marrow transplant. Which of the following are interventions specific for post-transplant nursing care?
The nurse is assessing a patient in the emergency room due to chest pain. To determine whether the patient's pain is due to a myocardial infarction, the nurse should note the pain:
The nurse is performing an initial assessment on a patient suspected of glomerulonephritis. Which symptoms would the nurse expect to observe?
A patient is scheduled to undergo an ultrasound to evaluate a renal mass. The nurse understands that an ultrasound is ordered, as opposed to other tests, because:
The nurse is providing colostomy education to a patient prior to discharge. The nurse knows that the patient did not understand the instructions when he states:
A nurse is caring for a patient suspected of having acute respiratory distress syndrome (ARDS). Which of the following assessment data would support the suspected diagnosis?
A patient has developed acute renal failure (ARF) with a 24-hour urine output of 350 ml. The nurse should assess the patient for:
A patient is being evaluated for polycystic kidney disease (PKD). The nurse assesses the patient expecting to note which common symptoms?
A family member of a client with severe dehydration asks the nurse, "What are the common causes of dehydration?" The nurse appropriately answers by explaining:
A nurse is caring for a 9-year-old child with scabies. The nurse would expect to see which of the following on the patient's skin?
A patient with acne vulgaris asks the nurse what additional steps she can take to reduce the number and severity of lesions. The nurse should mention which of the following interventions?
A patient has developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) after suffering a traumatic brain injury. After treatment has been initiated, the nurse assesses the patient for signs of improvement, including:
The nurse is initiating continuous bladder irrigation on a patient that just underwent a prostatectomy. The nurse understands that the flow rate is adequate if:
The nurse is providing dietary instructions to a patient with hypothyroidism. The nurse should encourage the patient to consume a diet: