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A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
- A. Avoid eating foods high in potassium.
- B. Avoid foods high in vitamin K.
- C. Take the medication on an empty stomach.
- D. Take the medication at bedtime for best results.
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.
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A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?
- A. Increase fluid intake to prevent crystalluria.
- B. Take the medication with meals to prevent GI upset.
- C. Avoid sunlight exposure while taking the medication.
- D. Report any changes in the color of urine.
Correct Answer: A
Rationale: The correct answer is to increase fluid intake to prevent crystalluria, a potential side effect of ciprofloxacin. Crystalluria is the formation of crystals in the urine, which can be reduced by maintaining adequate hydration. Choice B is incorrect because ciprofloxacin can be taken with or without food. Choice C is incorrect as avoiding sunlight exposure is more relevant for medications that cause photosensitivity, not typically a concern with ciprofloxacin. Choice D is less essential than choice A because while reporting changes in urine color is important, preventing crystalluria through adequate fluid intake is a higher priority.
A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?
- A. Take the medication with food to improve absorption.
- B. Avoid taking other pain medications to prevent liver damage.
- C. Take acetaminophen on an empty stomach to prevent stomach upset.
- D. Monitor liver function tests regularly to detect any liver damage.
Correct Answer: B
Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?
- A. Trendelenburg
- B. Supine
- C. Prone
- D. Fowler's
Correct Answer: D
Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.
A client with Alzheimer's disease is becoming increasingly confused. What action should the nurse take first?
- A. Reorient the client to time and place.
- B. Monitor the client's vital signs.
- C. Provide the client with calming activities to reduce confusion.
- D. Consult with the healthcare provider about adjusting the client's medication.
Correct Answer: B
Rationale: The correct action for the nurse to take first when a client with Alzheimer's disease is becoming increasingly confused is to monitor the client's vital signs (Choice B). Increased confusion in Alzheimer's disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.
During an excretory urogram, which observation made by the nurse indicates a complication?
- A. The client complains of a salty taste in the mouth when the dye is injected
- B. The client's entire body turns a bright red color
- C. The client states 'I have a feeling of getting warm.'
- D. The client gags and complains 'I am getting sick.'
Correct Answer: B
Rationale: The correct answer is B because a whole-body bright red color indicates a severe reaction to the contrast dye and must be addressed immediately. Choices A, C, and D do not indicate a severe complication during an excretory urogram. Choice A is a common side effect of the dye, choice C could be a normal sensation due to the injection, and choice D may indicate nausea which is less severe compared to a whole-body red color reaction.