The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
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Solution
Option D: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.
Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
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Solution
Option B: Mashed potatoes and broiled chicken are low in natural sodium chloride.
Options A, C, and D: Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
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Solution
Option C: A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time.
Options A and B: The physician is responsible for instructing the patient about the test and for writing the order for the test.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
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Solution
Option C: Orthopnea is difficulty of breathing except in the upright position.
Option A: Tachypnea is rapid respiration characterized by quick, shallow breaths.
Option B: Eupnea is normal respiration – quiet, rhythmic, and without effort.
The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…
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Solution
Option B: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation.
Options A and C: Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician.
Option D: Allowing for rest periods decreases the possibility of hypoxia.
The nurse prepares IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication?
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Solution
Option D: During the procedure, skin and tissue are pulled and held firmly while a long needle is inserted into the muscle. After the medication is injected, the skin and tissue are released. The needle track that forms during this procedure takes the shape of the letter “Z,” which gives the procedure its name. This zigzag track line is what prevents medication from leaking from the muscle into surrounding tissue.
Another name for knee-chest position is:
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Solution
Option B: Genu-pectoral position is the position of a patient in which the weight of the body is supported on the knees and chest.
The nurse asked the client to read the Snellen chart. Which of the following is tested:
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Solution
Option A: Cranial Nerve II or the optic nerve is tested through the use of the Snellen chart.
It refers to the manner of walking
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Solution
Option A: Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate.
The best position for examining the rectum is:
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Solution
Option C: To assume the genu-pectoral position the person kneels so that the weight of the body is supported by the knees and chest, with the buttocks raised. The head is turned to one side and the arms are flexed so that the upper part of the body can be supported in part by the elbows.