Nursing Care and Interventions Flashcards

A client is prescribed heparin infusion for deep vein thrombosis. The aPTT result comes back at 180 seconds (therapeutic range 60–100 seconds). What is the nurse's priority action?

Answer: Stop the infusion and notify the physician immediately

An aPTT of 180 seconds is dangerously supratherapeutic and increases bleeding risk; the nurse must stop the infusion and notify the physician immediately.

A postoperative client develops sudden onset dyspnea, chest pain, and tachycardia on day 2 after hip replacement surgery. The nurse suspects pulmonary embolism. What is the first action?

Answer: Administer supplemental oxygen and call the physician immediately

Administering supplemental oxygen addresses the immediate hypoxia of pulmonary embolism while the nurse simultaneously calls for emergency assistance.

A nurse is inserting an indwelling urinary catheter in a female client. After inserting the catheter approximately 5 cm, no urine returns. What is the most appropriate action?

Answer: Leave the catheter in place as a vaginal landmark and insert a new catheter into the urethra

If the catheter has entered the vagina, it should be left as a landmark to identify the correct urethral opening, and a new sterile catheter inserted into the urethra.

A client receiving a blood transfusion develops fever, chills, and back pain 15 minutes after the infusion begins. What is the nurse's immediate action?

Answer: Stop the transfusion, keep the IV line open with normal saline, and notify the physician

Signs of acute hemolytic transfusion reaction require stopping the transfusion immediately while maintaining IV access with normal saline and notifying the physician.

A client with diabetes mellitus is found unresponsive with a blood glucose of 2.1 mmol/L. The client has no IV access. What is the appropriate intervention?

Answer: Administer glucagon 1 mg intramuscularly

An unresponsive hypoglycemic client without IV access should receive glucagon IM, as oral administration is contraindicated without a gag reflex.

A nurse is caring for a client in traction for a femur fracture. Which assessment finding requires immediate reporting?

Answer: Absence of dorsiflexion and inability to feel the foot (foot drop)

Foot drop and loss of sensation indicate peroneal nerve compression or compartment syndrome, requiring immediate physician notification.

A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding requires the most urgent intervention?

Answer: Serum calcium of 2.0 mmol/L with positive Chvostek's sign

Hypocalcemia with a positive Chvostek's sign after thyroidectomy indicates accidental parathyroid damage and risk for tetany, requiring urgent treatment.