A nurse is reviewing the medical record of a client who is to undergo open heart surgery.

Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

Thrombocytopenia.

Rheumatoid arthritis.

Thalassemia.

COPD.

Answer and Explanation

The Correct Answer is A

Thrombocytopenia, or low platelet count, is a contraindication to receiving heparin.
Rheumatoid arthritis is not a contraindication to receiving heparin.
Thalassemia is not a contraindication to receiving heparin.
COPD is not a contraindication to receiving heparin.

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Correct Answer is C

Explanation

The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.

A. Respiratory acidosis. B. Metabolic alkalosis. C. Respiratory alkalosis. D. Metabolic acidosis.

Correct Answer is D

Explanation

The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis.
The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue.
The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.

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A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH 7.24, PaCO2 44 mm Hg, PaO2 84 mm Hg. HCO3 18 mEq/L, base excess -2, and O2 saturation 95%. The nurse should conclude that the client has which of the following acid-base imbalances?

Correct Answer is D

Explanation

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A nurse is reviewing the medical record of a client who is to undergo open heart surgery.

Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?