ATI Learning System PN Medical Surgical Final Quizlet

Correct Answer: B

Rationale: The partial thromboplastin time (PTT) is the laboratory test that should be monitored to evaluate the effectiveness of heparin therapy in patients with deep vein thrombosis (DVT). Heparin affects the intrinsic pathway of the coagulation cascade, which is reflected by changes in the PTT. Monitoring the PTT helps ensure that the patient's blood is within the desired therapeutic range and prevents complications related to clotting or bleeding.

Correct Answer: C

Rationale: The correct answer is C: Deep, rapid respirations (Kussmaul breathing). This is a sign of severe acidosis commonly seen in diabetic ketoacidosis (DKA) and requires immediate intervention. Kussmaul breathing helps to compensate for the metabolic acidosis by blowing off carbon dioxide. Prompt intervention is necessary to prevent further deterioration and potential respiratory failure.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. The nurse should monitor for signs of hyperkalemia, which is a potential side effect of spironolactone therapy. Hyperkalemia can lead to serious cardiac arrhythmias, so close monitoring of potassium levels is essential to prevent complications.

Correct Answer: B

Rationale: The correct instruction for a client with myasthenia gravis prescribed pyridostigmine (Mestinon) is to take the medication 30 minutes before meals. This timing is crucial as it helps improve muscle strength for eating and swallowing. By taking the medication before meals, the client can experience enhanced muscle function during mealtime, which is especially important for managing the symptoms of myasthenia gravis.

Correct Answer: C

Rationale: The correct instruction for a client learning to self-administer insulin is to rotate injection sites within the same region. This practice helps prevent lipodystrophy, which is a condition characterized by fat tissue changes due to repeated injections in the same spot, and also ensures consistent absorption of insulin throughout the body.