a nurse is caring for a client who is receiving warfarin coumadin therapy which of the following laboratory results should the nurse review to evaluat
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam

1. A client receiving warfarin (Coumadin) therapy should have which of the following laboratory results reviewed to evaluate the effectiveness of the therapy?

Correct answer: C

Rationale: The correct answer is C: International normalized ratio (INR). The INR is the most appropriate laboratory result to review when evaluating the effectiveness of warfarin (Coumadin) therapy. Warfarin is an anticoagulant medication, and the INR helps determine if the dosage is within a therapeutic range to prevent clotting or bleeding complications. Choice A, a Complete Blood Count (CBC), provides information about the cellular components of blood but does not directly assess the anticoagulant effects of warfarin. Choice B, Prothrombin time (PT), measures the time it takes for blood to clot but is not as specific for monitoring warfarin therapy as the INR. Choice D, Partial Thromboplastin Time (PTT), evaluates the intrinsic pathway of coagulation and is not the primary test used to monitor warfarin therapy.

2. The nurse is preparing to give trimethoprim-sulfamethoxazole (TMP-SMX) to a patient and notes a petechial rash on the patient’s extremities. The nurse will perform which action?

Correct answer: A

Rationale: When a patient on TMP-SMX presents with a petechial rash, it can be indicative of a severe adverse reaction such as thrombocytopenia or a hypersensitivity reaction. The appropriate action for the nurse to take in this situation is to hold the dose of TMP-SMX and notify the healthcare provider immediately. This is crucial to prevent further administration of a medication that may be causing a serious adverse effect. Requesting a blood glucose level (Choice B) is not relevant in this scenario as the patient's presentation is suggestive of a skin-related issue rather than a glucose-related problem. Similarly, requesting a BUN and creatinine level (Choice C) would not address the immediate concern of a petechial rash and its association with TMP-SMX. Requesting an order for diphenhydramine (Choice D) may help manage itching or mild allergic reactions but is not the priority when a petechial rash is observed, as it may indicate a more severe reaction requiring immediate intervention.

3. In a patient with chronic kidney disease, which of the following is a common complication?

Correct answer: A

Rationale: Hyperkalemia is a common complication in chronic kidney disease due to the kidneys' reduced ability to excrete potassium. As kidney function declines, potassium levels may increase, leading to hyperkalemia. Hypernatremia (increased sodium levels), hypocalcemia (low calcium levels), and hyperphosphatemia (elevated phosphate levels) are not typically associated with chronic kidney disease. Therefore, the correct answer is hyperkalemia.

4. A client who experienced partial-thickness burns involving over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea. The client's blood pressure is 82/40 mmHg, and temperature is 96°F (36.6°C). Which action is most important for the nurse to take?

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of sepsis, such as hypotension, hypothermia, and a recent history of partial-thickness burns with open wounds. The development of watery diarrhea further raises suspicion for sepsis. With a blood pressure of 82/40 mmHg and a low temperature of 96°F (36.6°C), the nurse should recognize the potential for septic shock. Notifying the rapid response team is crucial in this situation as the client requires immediate intervention and management to prevent deterioration and address the underlying septic process. Increasing the room temperature (Choice A) is not the priority as the low body temperature is likely due to systemic vasodilation and not environmental factors. While assessing oxygen saturation (Choice B) is important, the client's hypotension and hypothermia take precedence. Continuing to monitor vital signs (Choice C) alone is insufficient given the critical condition of the client and the need for prompt action to address the sepsis and potential septic shock.

5. A client receives a prescription for 1 liter of lactated Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is needed, round to the nearest whole number.)

Correct answer: A

Rationale: The correct infusion rate is 167 mL/hr. This is calculated by dividing the total volume (1000 mL) by the total time (6 hours), resulting in 166.67 mL/hr, which should be rounded to the nearest whole number as 167 mL/hr. This calculation ensures a steady infusion rate over the specified time frame. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation based on the volume and time provided in the prescription.

Similar Questions

Which of the following interventions is most appropriate for a patient with acute pancreatitis?
A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?
An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?
In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses