Question 1: A client with deep vein thrombosis (DVT) is receiving heparin therapy. What finding should the nurse report immediately?
Rationale: Blood in the urine may indicate bleeding, a serious complication of heparin therapy that requires immediate attention.
Question 2: A nurse is caring for a client with a nasogastric (NG) tube set to low intermittent suction. Which assessment finding requires intervention?
Rationale: Abdominal distention may indicate the NG tube is not functioning correctly, requiring assessment and intervention.
Question 3: A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 88%. What is the nurse’s priority action?
Rationale: Pursed-lip breathing can improve oxygenation and reduce air trapping in clients with COPD, making it the first intervention.
Question 4: A client with diabetes reports feeling shaky and dizzy. What is the nurse’s first action?
Rationale: Checking the client’s blood glucose level is the first step to confirm hypoglycemia before taking further actions.
Question 5: Which client statement indicates a need for further teaching about warfarin therapy?
Rationale: Warfarin must be taken consistently as prescribed, not based on symptoms, to maintain therapeutic anticoagulation levels.
