Nokea
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interact with this medication?
- A. Orange juice.
- B. Kale.
- C. Beef stew.
- D. Yogurt.
Correct Answer: B
Rationale: The correct answer is B: Kale. Kale is high in vitamin K, which can interfere with the anticoagulant effects of warfarin by increasing the clotting factors in the blood, leading to a decreased INR. It is important for patients on warfarin to maintain a consistent intake of vitamin K-rich foods to ensure their INR remains within the therapeutic range. Orange juice (A), beef stew (C), and yogurt (D) do not significantly interact with warfarin. A summary of why they are incorrect: Orange juice does not have a direct interaction with warfarin. Beef stew does not contain significant amounts of vitamin K. Yogurt is not a high vitamin K food.
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A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Oily skin
- B. Alopecia
- C. Increased salivation
- D. Diplopia
Correct Answer: B
Rationale: The correct answer is B: Alopecia. Alopecia, or hair loss, is a common manifestation of malnutrition due to inadequate intake of essential nutrients. Malnutrition can lead to hair thinning and loss. Oily skin (A) is more commonly associated with excess intake of fats. Increased salivation (C) is not a typical manifestation of malnutrition. Diplopia (D), or double vision, is not directly related to malnutrition.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries
- B. I often have diarrhea after eating scrambled eggs
- C. I have trouble urinating if I eat acidic foods
- D. I sometimes start to wheeze when I eat peanuts
Correct Answer: A
Rationale: The correct answer is A because a client who experiences a rash when eating strawberries may have a latex allergy due to cross-reactivity between latex and certain fruits like strawberries. This is known as latex-fruit syndrome. The other choices (B, C, D) do not indicate a potential latex allergy and are unrelated symptoms. It's important for the nurse to recognize this risk factor to prevent an allergic reaction during surgery.
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom dark at night.
- B. Cover electrical outlets in the client's home with tape.
- C. Hang a monthly calendar in the client's bedroom.
- D. Place a large face clock in the client's bedroom.
Correct Answer: D
Rationale: The correct answer is D: Place a large face clock in the client's bedroom. This is important for clients with Alzheimer's disease as it helps them maintain a sense of time and routine. People with Alzheimer's often struggle with time perception, so having a clock with large, easy-to-read numbers can assist them in understanding the time of day. This can help reduce confusion and anxiety.
A: Keeping the client's bedroom dark at night may increase confusion and disorientation for someone with Alzheimer's.
B: Covering electrical outlets with tape is not relevant to caring for a client with Alzheimer's at home.
C: Hanging a monthly calendar in the client's bedroom may not be as effective as a large face clock in helping the client understand time.
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching
- B. Move the client up and down in bed by holding onto the halo traction device
- C. Ensure that there is space for one finger to fit between the vest and the client's skin
- D. Loosen or tighten the screws on the device as needed for the client's comfort
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
- A. Neurovascular assessment
- B. Braden scale
- C. Pain assessment
- D. Morse Fall Risk scale
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.