Nokea
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
- A. Hamburger and French fries
- B. Large chef's salad and muffin
- C. No selection, spouse brings pizza
- D. Tuna salad sandwich and chips
Correct Answer: B
Rationale: Warfarin inhibits vitamin K-dependent clotting factors. A large chef's salad with leafy greens high in vitamin K can interfere with warfarin's effectiveness, indicating a need for further education.
You may also like to solve these questions
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
- A. Client who had a reaction to contrast dye yesterday
- B. Client with a new spinal cord injury on a rotating bed
- C. Middle-aged man with an exacerbation of asthma
- D. Older client who is 1-day post hip replacement surgery
- E. Young obese client with a fractured femur
Correct Answer: B,D,E
Rationale: Risk factors for PE include prolonged immobility (spinal cord injury, post-hip surgery), obesity, and trauma (fractured femur). Contrast dye reaction and asthma are not associated with increased PE risk.
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
- A. The client is able to initiate spontaneous breaths
- B. The inspired oxygen has adequate humidification
- C. The upper peak airway pressure limit alarm is off
- D. The upper peak airway pressure limit alarm is on
Correct Answer: D
Rationale: The upper peak airway pressure limit alarm must be on to prevent lung injury from excessive pressure. This is the priority to ensure client safety.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
- A. Decrease the heparin rate
- B. Increase the heparin rate
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
- A. Allow visitors at the client's bedside
- B. Ensure the client can communicate if awake
- C. Keep the television tuned to a favorite channel
- D. Provide back and hand massages when turning
- E. Turn the client every 2 hours or more
Correct Answer: A,B,D,E
Rationale: Comfort measures for ventilated clients include allowing visitors, enabling communication (e.g., via writing boards), providing massages during turning, and frequent repositioning to prevent pressure injuries. Keeping the TV on may disrupt rest.