Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

fine crackles

wheezes

rhonchi

vesicular sounds

Answer and Explanation

The Correct Answer is B

A.   Fine crackles - Fine crackles are short, popping sounds usually heard during inspiration, indicative of fluid in the lungs.
B.   Wheezes - Wheezes are continuous, high-pitched musical sounds caused by narrowed airways, often seen in asthma, bronchitis, or other respiratory conditions.
C.   Rhonchi - Rhonchi are low-pitched, rattling sounds that occur when air flows through thick mucus or secretions in the larger airways.
D.   Vesicular sounds - Vesicular breath sounds are normal lung sounds heard over most lung fields during inspiration. They are not continuous and high-pitched.

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Correct Answer is D

Explanation

A. Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B. Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C. Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D. The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

A. INR = 3.7 (normal 0.9-1.1) B. Hemoglobin = 6.3g/dL (normal Female: 11.7-15.5 g/dL: Male: 14-17:3 g/dL) C. Fibrinogen = 90mg/dL (normal 200-400mg/dL) D. Platelets = 101,000 mm3 (normal 150,000-450,000 mm3)

Correct Answer is A

Explanation

A. INR = 3.7: The International Normalized Ratio (INR) is a measure of blood clotting. An INR greater than
3.0 indicates that the blood is not clotting properly, which can be caused by warfarin overdose. An elevated INR requires FFP to correct coagulopathy.
B. Hemoglobin = 6.3g/dL: This is low, indicating anemia, but it is not directly related to warfarin overdose. The primary issue here is coagulopathy, not anemia.
C. Fibrinogen = 90mg/dL: Fibrinogen levels may be decreased in various conditions, but this alone does not necessarily require additional FFP unless it’s below a critical threshold. Fibrinogen is not the main marker for warfarin overdose.
D. Platelets = 101,000 mm3: This platelet count is within the lower end of the normal range but does not indicate that more FFP is needed in response to warfarin overdose.

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Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Correct Answer is D

Explanation

The nurse is caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

Correct Answer is A

Explanation

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