Nokea
A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
- A. Dietary restrictions
- B. Driving restrictions
- C. Follow-up laboratory monitoring
- D. Drug-drug interactions
- E. Reason to take medication
Correct Answer: A,C,D,E
Rationale: Clients on warfarin need instructions on dietary restrictions, follow-up monitoring, drug interactions, and the reason for the medication, per The Joint Commission's Core Measures. Driving restrictions are not typically required.
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An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
- A. Assess the client's neurological status
- B. Notify the Rapid Response Team
- C. Prepare to administer vitamin K
- D. Turn down the infusion rate
Correct Answer: B
Rationale: Clients on fibrinolytic therapy are at high risk of bleeding. Sudden neurologic signs may indicate a hemorrhagic stroke. The nurse should first call the Rapid Response Team based on the client's manifestations, then perform a thorough neurological examination.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.