Prothrombin time (PT) is a measure of how long it takes for blood to clot. Warfarin is an anticoagulant that prolongs the PT and prevents blood clots from forming. The nurse should monitor the PT and adjust the warfarin dose accordingly to maintain a therapeutic range.

Incorrect choices:

b) Activated partial thromboplastin time (aPTT): aPTT is another measure of blood clotting time, but it is used to monitor heparin therapy, not warfarin therapy.

c) Platelet count: Platelet count is a measure of how many platelets are in the blood. Platelets are involved in blood clotting, but they are not affected by warfarin therapy.

d) Hemoglobin level: Hemoglobin level is a measure of how much oxygen-carrying protein is in the blood. Haemoglobin level can be affected by bleeding or anaemia, but it is not directly related to warfarin therapy.

Using the same finger for each blood glucose test can cause pain, infection, and callus formation. The client should rotate the fingers and use different sites for each test.

Incorrect choices:

a) "I should check my blood glucose before meals and at bedtime.": This is correct as it follows the recommended frequency of SMBG for most clients with diabetes mellitus.

c) "I should wash my hands with soap and water before each test.": This is correct as it prevents contamination and ensures the accuracy of the test results.

d) "I should record my blood glucose results in a log book.": This is correct as it helps the client and the health care team to evaluate the effectiveness of the diabetes management plan.

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure by blocking the conversion of angiotensin I to angiotensin II, which causes vasoconstriction. Spironolactone is a potassium-sparing diuretic that lowers blood pressure by increasing urine output and preventing sodium and water reabsorption.

However, both medications can also increase potassium levels in the blood, which can lead to hyperkalemia, a potentially life-threatening condition. The nurse should hold both medications and notify the provider of this potential drug interaction.

Incorrect choices:

a) Administer both medications as ordered: This is incorrect as it exposes the client to the risk of hyperkalemia.

c) Hold lisinopril and administer spironolactone: This is incorrect as it does not eliminate the risk of hyperkalemia from spironolactone alone.

d) Hold spironolactone and administer lisinopril: This is incorrect as it does not eliminate the risk of hyperkalemia from lisinopril alone.

Using a latex-free syringe and needle is the appropriate action to prevent an allergic reaction in a client who has a latex allergy. The nurse should also check the medication label and vial for any latex content.

Incorrect choices:

b) Apply a latex bandage over the injection site: This is incorrect as it can cause skin irritation and allergic reaction in a client who has a latex allergy.

c) Wear latex gloves during the procedure: This is incorrect as it can expose the client and the nurse to latex particles and cause an allergic reaction.

d) Dilute the medication with normal saline: This is incorrect as it can alter the concentration and effectiveness of the medication.

Consuming alcohol on a regular basis is a modifiable risk factor for developing breast cancer. The nurse should ask this question to assess the client's current lifestyle habits and provide education on reducing alcohol intake.

Incorrect choices:

a) "Have you ever had a mammogram?": This is incorrect as it does not assess a risk factor for developing breast cancer, but rather a screening method for detecting breast cancer.

b) "Do you perform monthly breast self-examinations?": This is incorrect as it does not assess a risk factor for developing breast cancer, but rather a preventive measure for early detection of breast cancer.

c) "Have you ever used oral contraceptives?": This is incorrect as it does not assess a current risk factor for developing breast cancer, but rather a past exposure that may or may not have an effect on the client's risk.

Maintaining the current oxygen flow rate is the appropriate action for the nurse to take. Clients who have COPD have chronically low oxygen saturation levels and high carbon dioxide levels due to impaired gas exchange. Increasing the oxygen flow rate can cause oxygen toxicity and suppress the respiratory drive, leading to respiratory failure. The nurse should aim to keep the oxygen saturation level between 88% and 92% for clients who have COPD.

Incorrect choices:

a) Increase the oxygen flow rate to 4 L/min: This is incorrect as it can cause oxygen toxicity and suppress the respiratory drive, leading to respiratory failure.

b) Encourage the client to cough and deep breathe: This is incorrect as it can increase the work of breathing and cause fatigue and dyspnea in clients who have COPD.

c) Administer bronchodilator medication as prescribed: This is incorrect as it does not address the immediate issue of low oxygen saturation level. Bronchodilator medication can help improve airflow and reduce airway inflammation, but it does not directly increase oxygen delivery.