Nokea
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the Coumadin dosage
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of neurological assessments
Correct Answer: A
Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.
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A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
A Mexican-American client states that she and her family live next door to her brother and his family and that they share goods, services, and childcare. How is this type of family classified?
- A. Nuclear
- B. Dual career/dual earner
- C. Extended
- D. Extended kin network
Correct Answer: D
Rationale: An extended kin network (D) involves close-knit families sharing resources and responsibilities, as described.
A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?
- A. It's normal to be scared. You are safe here. Let's discuss the procedure.
- B. I'll ask the cardiologist to come and speak with you about your concerns.
- C. We have the best outcomes of any facility in the area for this procedure.
- D. Don't worry. The procedure has improved a lot in the last 10 years.
Correct Answer: A
Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.
A client undergoing 'cold-turkey' withdrawal from years of substance abuse is most at risk of serious life-threatening complications with which of the following substances?
- A. Heroin.
- B. Cocaine.
- C. Alcohol.
- D. Marijuana.
Correct Answer: C
Rationale: Alcohol withdrawal (C) can cause life-threatening complications like seizures and delirium tremens. Heroin (A), cocaine (B), and marijuana (D) withdrawal, while uncomfortable, are less likely to be fatal.
Clients taking anticholinergic drugs, such as benztropine mesylate (Cogentin), to relieve muscle tremors and muscle rigidity associated with Parkinson disease should be advised to avoid which of the following?
- A. Overheating
- B. Overeating
- C. Excessive fluid intake
- D. Skipping meals
Correct Answer: A
Rationale: Anticholinergics like benztropine reduce sweating, increasing the risk of overheating (A). Overeating (B), excessive fluids (C), or skipping meals (D) are not directly related to anticholinergic side effects.