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A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct choices are C (Aspirin) and E (Naproxen) because they both increase the risk of bleeding when used with warfarin, an anticoagulant. Aspirin and Naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can further inhibit platelet function and prolong bleeding time, leading to potential complications. Ferrous sulfate (A) is an iron supplement and does not directly interact with warfarin. Echinacea (B) is an herbal supplement with minimal known interactions with warfarin. Dextromethorphan (D) is a cough suppressant and does not impact warfarin's anticoagulant effects. In summary, the nurse should instruct the client to avoid Aspirin and Naproxen to prevent potential bleeding complications when taking warfarin.
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A nurse is providing teaching to a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: Avoiding crowds helps reduce the risk of exposure to infections, crucial for neutropenic clients.
C: Taking temperature daily allows early detection of fever, a sign of infection.
B: Weekly toothbrush washing does not directly impact infection risk.
D: Fresh fruits and vegetables are good for health but not specific to neutropenia management.
A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
- A. The client moves the cane 2 feet ahea
- B. The client advances the weaker leg forward to the cane.
- C. The client takes a step with their right foot first.
- D. The client holds the cane with their left han
Correct Answer: B
Rationale: The correct answer is B. Advancing the weaker leg forward to the cane provides stability and support, helping distribute weight evenly and preventing falls. This step is crucial in using a quad cane effectively. Moving the cane too far ahead (A) could cause imbalance. Taking a step with the stronger leg first (C) would not provide the needed support for the weaker side. Holding the cane with the same side as the weakness (D) may not provide the necessary support. It is essential to prioritize stability and weight distribution, making option B the correct choice.
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I should apply antibiotic ointment to the lesions.'
- B. I should use natural skin condoms during sexual intercourse.'
- C. I should expect my lesions to resolve in 6 weeks.'
- D. I should expect to take my medication for 3 weeks.'
Correct Answer: C
Rationale: The correct answer is C: "I should expect my lesions to resolve in 6 weeks." This indicates effectiveness of teaching because it shows the client understands the natural course of genital herpes and the expected timeline for resolution. Choice A is incorrect because antibiotic ointment is not recommended for herpes. Choice B is incorrect because natural skin condoms do not provide adequate protection against herpes. Choice D is incorrect because treatment duration may vary and is not always 3 weeks.
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.