Nokea
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. If you forget to take your morning dose, double the night time dose.'
- B. You should take aspirin instead of acetaminophen (Tylenol) for headaches.'
- C. Carry a medications alert card with you at all times.'
- D. You should use a straight-edge razor when shaving your arms and legs.'
Correct Answer: C
Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
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A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client.
- B. Explain to the nurse that there is no risk to the client.
- C. Ask the nurse if the chickenpox have crusted.
- D. Ask the nurse if she has ever had the chickenpox.
Correct Answer: D
Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Urine output 22 mL/hr for 2 hours
- B. Serum potassium level of 3.7
- C. Small T wave of ECG
- D. Serum glucose level of 180
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
- A. Risk for deficient fluid volume related to excessive fluid loss from ostomy
- B. Disturbed body image related to presence of ostomy
- C. Risk for impaired skin integrity related to irritation from ostomy appliance
- D. Deficient knowledge of ostomy care related to unfamiliarity with information resources
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
- A. Dried beans
- B. Swiss cheese
- C. Peanut butter
- D. Colby cheese
Correct Answer: D
Rationale: Colby cheese is high in sodium, which should be avoided on a sodium-restricted diet to manage hypertension, unlike the other options, which are lower in sodium.