Nokea
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
You may also like to solve these questions
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse is best?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Obtain a STAT chest X-ray
- C. Prepare to administer thrombolytic therapy
- D. Monitor the client's blood pressure every 15 minutes
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
- A. Decrease the heparin rate
- B. Increase the heparin rate
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
- A. Apply oxygen at 100%
- B. Assess the respiratory rate
- C. Ensure a patent airway
- D. Start two large-bore IV lines
Correct Answer: C
Rationale: For chest trauma, the priority follows the ABCs (airway, breathing, circulation). Ensuring a patent airway is the first step to stabilize the client.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
- A. Acknowledge the frightening nature of the illness
- B. Delegate a back rub to the unlicensed assistive personnel
- C. Give simple explanations of what is happening
- D. Request a prescription for anti-anxiety medication
- E. Stay with the client and speak in a quiet, calm voice
Correct Answer: A,B,C,E
Rationale: Anxiety is common in PE. Acknowledging fears, delegating comfort measures like a back rub, providing simple explanations, and staying with the client in a calming manner are appropriate to reduce anxiety without routinely using medications, which may worsen hypoxia.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client does not appear to be moving normally with respirations, oxygen saturation is 92%. What action by the nurse is best?
- A. Administer oxygen via non-rebreather mask
- B. Perform a rapid trauma assessment
- C. Prepare for chest tube insertion
- D. Obtain a chest X-ray immediately
Correct Answer: A
Rationale: The client's abnormal respiratory movement and low oxygen saturation suggest a traumatic chest injury, possibly pneumothorax or hemothorax. Administering oxygen via a non-rebreather mask is the priority to address hypoxia while further assessment is conducted.