The nurse is reviewing the lab results of a patient who takes warfarin to prevent deep vein thrombosis. Which laboratory result requires follow up by the nurse?

The partial thromboplastin time is 30 seconds

The International normalized ratio is 6.0

Creatinine is 12

The patient's hematocrit level is 43%

Answer and Explanation

The Correct Answer is B

A. The partial thromboplastin time is 30 seconds:

The partial thromboplastin time (PTT) measures the clotting time of blood and is typically used to monitor patients on heparin therapy, not warfarin. A PTT of 30 seconds is within the normal range and does not directly relate to warfarin therapy. Therefore, it does not require immediate follow-up in the context of warfarin administration.

B. The International normalized ratio is 6.0:

The International Normalized Ratio (INR) is a standard measure used to monitor the effectiveness of warfarin therapy. For most indications, the therapeutic range for INR is typically between 2.0 and 3.0. A value of 6.0 indicates that the patient's blood is taking six times longer to clot than normal, suggesting a significantly increased risk of bleeding. Therefore, this result requires immediate follow-up by the nurse to assess the patient's condition and potentially adjust warfarin dosage to reduce the risk of bleeding.

C. Creatinine is 12:

Creatinine is a waste product generated by muscle metabolism and is filtered out of the blood by the kidneys. Elevated levels of creatinine may indicate impaired kidney function, but this result does not directly relate to warfarin therapy. While an elevated creatinine level may require follow-up for other reasons, it does not necessitate immediate action related to warfarin therapy.

D. The patient's hematocrit level is 43%:

Hematocrit is a measure of the proportion of red blood cells in the blood. A hematocrit level of 43% is within the normal range for both men and women and does not directly relate to warfarin therapy. While changes in hematocrit may occur in some patients taking warfarin, this result alone does not require immediate follow-up in the context of warfarin administration.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Urinary retention: While urinary retention can occur in conditions such as benign prostatic hyperplasia or neurogenic bladder, it is not a typical manifestation of hypertensive emergency. Hypertensive emergencies primarily involve acute and severe elevations in blood pressure, which can lead to target organ damage, but urinary retention is not a direct consequence.

B. Headache: Headache is a common symptom associated with hypertension, especially during hypertensive emergencies. However, it is not specific to hypertensive emergencies and can occur in less severe cases of hypertension as well.

C. Jaundice: Jaundice is not a typical manifestation of hypertensive emergency. It is more commonly associated with liver dysfunction or hemolytic disorders rather than acute elevations in blood pressure.

D. Tachycardia: Tachycardia, or an elevated heart rate, is a hallmark sign of hypertensive emergency. When blood pressure rises significantly, the heart may respond by increasing its rate to maintain cardiac output. Tachycardia is indicative of the body's compensatory mechanisms in response to the acute hypertension and can be a sign of impending cardiovascular complications.

A. Monitors the patient's temperature, heart rate, respiratory rate and blood pressure. B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums. C. C Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours. D. Provides nutritional support if patient is unable to take sufficient amounts by mouth.

Correct Answer is C

Explanation

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the lab results of a patient who takes warfarin to prevent deep vein thrombosis. Which laboratory result requires follow up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient who is complaining of blurred vision. The patient's blood pressure reading is 195/130, the heart rate is 95 beats per minute. Which assessment finding by the nurse is consistent with a diagnosis of hypertensive emergency?

Correct Answer is D

Explanation

A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

Correct Answer is C

Explanation

The nurse is caring for a patient who has been taking metoprolol as a second medication to control hypertension. The nurse will assess for which side effect?

The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

A nurse is providing education of enoxaparin to a patient diagnosed with deep venous thrombosis. Which statement by the patient indicates understanding of the teaching?

During a health education session, a participant asked the nurse about the hepatitis B virus. What measure will the nurse recommend for preventing infection with this virus?

The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?

A nurse is teaching a patent who is taking warfarin for deep venous thrombosis. Which statement by the patient indicates a need for further teaching?

A nurse is preparing to administer total parental nutrition (TPN) 1000 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr.? (Round the answer to the nearest whole number. Use a leading zero fit applies. Do not use a trailing zero.)