27&28 sg

A patient is taking warfarin (Coumadin) after an artificial heart valve replacement procedure. The international normalized ratio result is 2.6. Which action by the nurse is correct?

• Restrict activity until bleeding risk is over.

• No action needs to be taken at this time.

• 1. Expect the provider to increase the dose of warfarin.

• 1. Administer vitamin K according to protocol.

The LPN/LVN is assisting the registered nurse in caring for a patient who is receiving a blood transfusion of two units of packed red blood cells. After checking the LPN/LVN is leaving the unit for a break. What information is essential to include in a focused SBAR handoff to the registered nurse ? Select all that apply .

• 1. Results of a complete head-to-toe examination

• 1. A report of the patient's pain on a 0 to 10 scale

• 1. The ABO blood type and Rh factor

• Current vital signs

• Status of patient’s comfort level

The nurse is preparing to assist the physician with a bone marrow biopsy. Which intervention is most important for the nurse to carry out before the procedure?

• Explain the procedure to the patient’s family.

• administer an analgesic to the pt

• Observe the patient for bleeding.

• Drape the biopsy site.

The nurse is providing care for patients on a medical-surgical unit. Which of the following patients is at increased risk for infection?

• A 75-year-old with a white blood cell count of 6,500/mm3.

• A 63-year-old with a platelet count of 110,000/mm3.

• A 49-year-old with a hematocrit level of 44%.

• An 88-year-old with a neutrophil count of 32%.

The nurse is caring for a patient receiving packed red blood cells. They are piggybacked into an IV of dextrose and water. A separate IV site is being used for antibiotic administration and appears to be clotted. What should the LPN/LVN immediately report to the RN?

• Blood should not be piggybacked into a primary IV.

• The clotted IV is not allowing the antibiotic to run.

• The blood is piggybacked into dextrose and water solution.

• The most recent set of vital signs.

Which of the following actions should the nurse prioritize when taking care of a patient with a platelet count of 23,000/mm³?

• Request an order for an anticoagulant.

• Protect the patient from injury.

• Encourage the patient to drink plenty of fluids.

• No action is necessary. This is a normal level.

A nurse is collecting patient data and finds small red-purple dots over most skin surfaces. The patient denies noticing them before. Which action should the nurse take first?

• Report the findings immediately to the registered nurse or health-care provider.

• Document the findings objectively in the medical record.

• Assist the patient to apply lotion.

• Administer an antihistamine as needed.

A nurse is preparing a patient for lymphangiography. Which statement by the patient shows that more teaching is needed?

• My skin might turn a bluish color.

• I will need a sandbag on my groin to prevent bleeding.

• My nurse will be checking my circulation routinely after the procedure.

• I will need more x-rays tomorrow.

Which of the following activities should be carried out to keep the patient safe before starting a blood transfusion? Select all that apply.

• Check the patient's vital signs.

• Match the room number to the order.

• Match the blood to the order.

• Check the temperature of the blood.

• Match the patient to the blood.

A nurse is monitoring a patient during a blood transfusion. After the blood has been hanging for 30 minutes, the patient's temperature rises from 98.6°F (37°C) at baseline to 101°F (38.3°C). The patient also experiences severe chills. Which action should the nurse take first?

• Document the vital signs in the medical record.

• Administer acetaminophen for the fever.

• Notify the health-care provider of the change.

• Stop the transfusion and hang normal saline solution.