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A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following statements should the nurse include?
- A. You should avoid eating spinach and kale.
- B. You can take ibuprofen for a headache.
- C. You should take the medication at bedtime.
- D. You can continue to participate in contact sports.
Correct Answer: A
Rationale: Spinach and kale, high in vitamin K, can interfere with warfarin's anticoagulant effect. Ibuprofen, variable dosing times, or contact sports increase bleeding risks.
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A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following findings should the nurse report to the provider?
- A. The client reports chest discomfort.
- B. The client's temperature is 38.4°C (101.1°F).
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: B
Rationale: A temperature of 38.4°C suggests infection, requiring reporting. Chest discomfort, minimal drainage, and normal BP are expected or less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for losartan. Which of the following statements should the nurse include?
- A. You should take this medication with a high-potassium meal.
- B. You might experience dizziness while taking this medication.
- C. You need to limit your exercise while taking this medication.
- D. You can take this medication at any time of day.
Correct Answer: B
Rationale: Losartan can cause dizziness due to blood pressure lowering, a key safety concern. Potassium meals, exercise limits, or flexible timing aren't primary considerations.
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for?
- A. Hypotension
- B. Hyperglycemia
- C. Hypocalcemia
- D. Bradycardia
Correct Answer: C
Rationale: Thyroidectomy risks hypoparathyroidism, leading to hypocalcemia, which can cause tetany or seizures. Hypotension, hyperglycemia, or bradycardia aren't primary concerns.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild fatigue.
- B. The client's IV site is cool and swollen.
- C. The client's urine output is 200 mL over 4 hr.
- D. The client's temperature is 37.2°C (99°F).
Correct Answer: B
Rationale: A cool, swollen IV site suggests extravasation, a chemotherapy emergency requiring reporting. Fatigue, normal urine output, and mild fever are less urgent.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.