A nurse is reviewing laboratory results for a client who is taking warfarin. Which of the following laboratory tests determines if the dose of medication is within the recommended target range?

Bleeding time

Factor VIII

aPTT

INR

Answer and Explanation

The Correct Answer is D

Choice A reason: Bleeding time assesses platelet function, not warfarin’s anticoagulant effect. Warfarin inhibits vitamin K-dependent clotting factors, unrelated to platelets. Monitoring bleeding time does not reflect therapeutic anticoagulation levels, making it irrelevant for adjusting warfarin doses to prevent thrombosis or bleeding.
Choice B reason: Factor VIII, deficient in hemophilia A, is not affected by warfarin, which targets vitamin K-dependent factors (II, VII, IX, X). Measuring Factor VIII does not indicate warfarin’s efficacy, as it is unrelated to the drug’s mechanism, making it unsuitable for dose monitoring.
Choice C reason: aPTT monitors heparin’s effect on the intrinsic clotting pathway, not warfarin’s action on vitamin K-dependent factors. Warfarin requires INR for therapeutic monitoring, as aPTT is insensitive to its effects, making it inappropriate for assessing warfarin’s anticoagulation range in patients.
Choice D reason: INR standardizes prothrombin time, measuring warfarin’s effect on vitamin K-dependent clotting factors. It ensures therapeutic anticoagulation (e.g., INR 2-3), preventing thrombosis or bleeding. INR is the gold standard for warfarin monitoring, guiding dose adjustments for safe and effective therapy.

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Correct Answer is A

Explanation

Choice A reason: Using a mechanical lift for a 136 kg client unable to assist ensures safety for both client and nurse. Lifts prevent injury by supporting the client’s weight, reducing strain on staff. This adheres to safe patient handling guidelines, minimizing risks of falls or musculoskeletal injuries during transfer.
Choice B reason: Asking another nurse to assist is insufficient for a 136 kg client unable to help, as manual lifting risks injury to staff and client. Mechanical lifts are required for heavy or non-assistive clients to ensure safety, making this option inadequate and unsafe for the transfer scenario described.
Choice C reason: Positioning the client upright before transfer is impractical for a non-assistive client weighing 136 kg, as it requires significant manual effort and risks injury. Mechanical lifts are needed to safely move such clients, ensuring stability and preventing falls, making this action inappropriate for the transfer.
Choice D reason: A sliding board is unsuitable for a 136 kg client unable to assist, as it requires some patient cooperation and strength. It risks injury to staff and client due to the client’s weight and inability to participate. Mechanical lifts are the safer, recommended method for this transfer.

A. The child usually has an aura before the seizure. B. This type of seizure lasts 30 to 60 seconds. C. This type of seizure requires surgical intervention. D. The child may appear to be daydreaming during the seizure.

Correct Answer is D

Explanation

Choice A reason: Absence seizures lack an aura, unlike focal seizures. They involve brief, sudden lapses in consciousness due to generalized cortical discharges, without premonitory symptoms, making this incorrect for educating parents about the characteristics of absence seizures in children.
Choice B reason: Absence seizures last 5-20 seconds, not 30-60 seconds. These brief staring spells are caused by spike-wave discharges on EEG. Prolonged duration suggests other seizure types, making this inaccurate for teaching parents about absence seizure presentation and duration.
Choice C reason: Absence seizures are managed with anticonvulsants like ethosuximide, not surgery. Surgical intervention is for refractory focal seizures, not generalized absence seizures, which respond to medication. This is incorrect for educating parents about treatment options for absence seizures.
Choice D reason: Absence seizures cause a daydreaming appearance, with staring and brief unresponsiveness due to synchronized cortical discharges. This hallmark symptom, lasting seconds, is critical for parents to recognize, aiding identification and management of absence seizures in school settings.

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A nurse is reviewing laboratory results for a client who is taking warfarin. Which of the following laboratory tests determines if the dose of medication is within the recommended target range?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take?

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

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A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?