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A nurse is providing discharge teaching for a patient who has a new prescription for warfarin. Which of the following instructions should the nurse include? What instructions should the nurse include for warfarin?
- A. Avoid foods high in vitamin K.
- B. Take the medication in the morning.
- C. Increase intake of vitamin C.
- D. Use a hard-bristled toothbrush.
Correct Answer: A
Rationale: The correct answer is A: "Avoid foods high in vitamin K." Warfarin is a blood thinner that works by decreasing the blood's ability to clot. Vitamin K can counteract the effects of warfarin, so patients should avoid consuming large amounts of foods high in vitamin K, such as leafy greens. This instruction is crucial to ensure the medication's effectiveness and prevent complications like blood clots. Taking warfarin in the morning (B) or increasing vitamin C intake (C) does not directly impact its effectiveness. Using a hard-bristled toothbrush (D) can increase the risk of bleeding gums but is not a primary concern with warfarin therapy.
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A nurse is caring for a patient who is postoperative following a knee arthroscopy. Which of the following actions should the nurse take? Which action should the nurse take post-knee arthroscopy?
- A. Apply a warm compress to the surgical site.
- B. Keep the leg in a dependent position.
- C. Encourage weight-bearing immediately.
- D. Elevate the affected leg.
Correct Answer: D
Rationale: The correct action is to elevate the affected leg post-knee arthroscopy. Elevating the leg helps reduce swelling and promote circulation, aiding in the healing process. Keeping the leg in a dependent position (choice B) can increase swelling. Applying a warm compress (choice A) may also increase swelling. Encouraging weight-bearing immediately (choice C) can put stress on the surgical site and delay healing. Thus, elevating the affected leg is the most appropriate action in this scenario.
A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson's stages of psychosocial development in order from birth to adolescence. Arrange Erikson's stages from birth to adolescence.
- A. Identity vs. role confusion
- B. Trust vs. mistrust
- C. Industry vs. inferiority
- D. Autonomy vs. shame and doubt
- E. Initiative vs. guilt
Correct Answer: B,D,E,C,A
Rationale: 1. Trust vs. mistrust comes first as it pertains to infancy and the development of basic trust in caregivers.
2. Autonomy vs. shame and doubt follows, focusing on toddlers developing independence.
3. Initiative vs. guilt is next, focusing on preschoolers exploring and taking initiative.
4. Industry vs. inferiority is about school-aged children developing competence.
5. Identity vs. role confusion is about adolescents forming a sense of self.
Therefore, the correct order is B, D, E, C, A. Other choices are incorrect as they do not align with the chronological order of Erikson's stages.
A nurse is instructing a female client on how to collect a midstream urine sample. Which statement from the client indicates they understand the procedure?,Which statement indicates understanding of midstream urine sample collection?
- A. I will clean the inside of the container with a wipe.
- B. I will urinate a little then stop.
- C. I will use each cleansing wipe twice.
- D. I will use the cleansing wipe from front to back.
Correct Answer: B
Rationale: The correct answer is B. By urinating a little first and then stopping, the client can discard the initial stream that may contain contaminants from the urethra, ensuring a more accurate midstream sample. Cleaning the container with a wipe (A) does not pertain to the collection process. Using cleansing wipes twice (C) risks contamination. Using the wipe from front to back (D) is not relevant to urine sample collection.
A nurse is caring for a patient who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse monitor? Which lab test should the nurse monitor for heparin?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). aPTT is the most appropriate lab test to monitor for patients receiving heparin therapy because it reflects the drug's anticoagulant effect. Heparin works by inhibiting thrombin and factor Xa, which can be measured effectively by monitoring aPTT levels. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for potential heparin-induced thrombocytopenia, but aPTT is more directly related to heparin's anticoagulant effect.
A nurse is caring for a patient who has a new prescription for prednisone. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for prednisone?
- A. Hypoglycemia
- B. Weight gain
- C. Hypotension
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite. The rationale for this is that prednisone can alter metabolism, leading to redistribution of body fat and increased retention of sodium and water. Monitoring for weight gain is crucial to assess the effectiveness of the medication and to prevent complications such as edema and hypertension.
Regarding the other choices:
A: Hypoglycemia - Prednisone typically causes hyperglycemia, not hypoglycemia.
C: Hypotension - Prednisone can lead to fluid retention and increased blood pressure, not hypotension.
D: Bradycardia - Prednisone does not commonly cause bradycardia; it can actually lead to an increased heart rate.