CPNRE Nursing Care and Interventions 5 — Questions and Answers
Question 1: 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?
- Continue the infusion and recheck aPTT in 6 hours
- Stop the infusion and notify the physician immediately (Correct answer)
- Decrease the infusion rate by 10% and recheck in 4 hours
- Administer protamine sulfate and await physician orders
Correct 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.
Question 2: 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?
- Obtain a 12-lead ECG
- Administer supplemental oxygen and call the physician immediately (Correct answer)
- Position the client flat to improve venous return
- Draw blood for a D-dimer level
Correct 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.
Question 3: 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?
- Advance the catheter another 5 cm and inflate the balloon
- Withdraw the catheter, discard it, and begin the procedure again with a new sterile catheter
- Leave the catheter in place as a vaginal landmark and insert a new catheter into the urethra (Correct answer)
- Rotate the catheter 180 degrees and attempt to advance further
Correct 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.
Question 4: 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?
- Slow the infusion rate and administer acetaminophen
- Stop the transfusion, keep the IV line open with normal saline, and notify the physician (Correct answer)
- Stop the transfusion and remove the IV line immediately
- Administer diphenhydramine IV and continue the transfusion at a slower rate
Correct 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.
Question 5: 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?
- Administer oral glucose gel between the cheek and gum
- Call a code and initiate CPR
- Administer glucagon 1 mg intramuscularly (Correct answer)
- Insert a nasogastric tube and administer 50% dextrose
Correct 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.
Question 6: A nurse is caring for a client in traction for a femur fracture. Which assessment finding requires immediate reporting?
- Mild discomfort at the pin insertion sites
- Capillary refill of 2 seconds in the affected extremity
- Absence of dorsiflexion and inability to feel the foot (foot drop) (Correct answer)
- Client reports the weights feel heavy
Correct 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.
Question 7: A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding requires the most urgent intervention?
- Mild hoarseness of voice
- Serum calcium of 2.0 mmol/L with positive Chvostek's sign (Correct answer)
- Serous drainage on the dressing
- Complaint of sore throat when swallowing
Correct 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.
CPNRE Nursing Care and Interventions 5
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?