Nokea
A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?
- A. I will need to increase my intake of leafy green vegetables.
- B. I will avoid drinking grapefruit juice while taking warfarin.
- C. I will have my INR checked regularly.
- D. I will take my medication at the same time each day.
Correct Answer: C
Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.
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A client is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Encourage the client to remain on bed rest.
- B. Massage the client's legs every 4 hours.
- C. Apply sequential compression devices to the client's legs.
- D. Administer anticoagulants as prescribed.
Correct Answer: C
Rationale: The correct action the nurse should take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (Choice A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (Choice B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (Choice D) is a treatment for DVT, it is not a preventive measure for a client at risk.
What is the best way to assess a patient's respiratory function after surgery?
- A. Check oxygen saturation
- B. Auscultate lung sounds
- C. Check for abnormal breath sounds
- D. Check skin color
Correct Answer: A
Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.
How should a healthcare professional monitor a patient with a central line for infection?
- A. Monitor the dressing site daily
- B. Check for redness and swelling
- C. Monitor for fever
- D. Flush the central line
Correct Answer: A
Rationale: Monitoring the dressing site daily is crucial for detecting early signs of infection in patients with central lines. Checking for redness and swelling (choice B) is important but may indicate a more advanced stage of infection. Monitoring for fever (choice C) can also be a sign of infection, but it is a later manifestation. Flushing the central line (choice D) is necessary for maintaining patency but does not directly monitor for infection.
When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with the removal
- D. Increase fluid intake before the procedure
Correct Answer: A
Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.
Which lab value is critical for a patient on heparin therapy?
- A. Monitor aPTT
- B. Monitor INR
- C. Monitor platelet count
- D. Monitor sodium levels
Correct Answer: A
Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial for patients on heparin therapy as it helps determine the clotting ability of the blood. By monitoring aPTT, healthcare providers can adjust the dosage of heparin to maintain therapeutic levels and prevent bleeding complications. Monitoring INR is more commonly associated with warfarin therapy, not heparin. Monitoring platelet count is important for assessing the risk of bleeding or clotting disorders but is not specific to heparin therapy. Monitoring sodium levels is not directly related to assessing the effectiveness or safety of heparin therapy.