Nokea
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
- A. Orange juice
- B. Cabbage
- C. Beef stew
- D. Vegetable oil
Correct Answer: B
Rationale: The correct answer is B: Cabbage. Cabbage is high in vitamin K, which can counteract the effects of warfarin, a medication that works by blocking the action of vitamin K in the blood. Consuming large amounts of foods high in vitamin K, like cabbage, can decrease the effectiveness of warfarin and increase the risk of blood clots. Orange juice (A), beef stew (C), and vegetable oil (D) do not significantly affect INR levels or interact with warfarin in the same way as vitamin K-rich foods like cabbage.
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A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to excessive loss of proteins in the urine, specifically albumin. This results in proteinuria. Choice A, hyperalbuminemia, is incorrect as nephrotic syndrome actually causes hypoalbuminemia due to protein loss. Choice C, decreased serum lipid levels, is incorrect because nephrotic syndrome causes hyperlipidemia due to increased hepatic synthesis of lipoproteins. Choice D, decreased coagulation, is incorrect as nephrotic syndrome is associated with hypercoagulability due to loss of anticoagulant proteins in the urine.
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person place and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic cough is productive and mucous is yellow in color.
Correct Answer: D
Rationale: The correct answer is D because tachypnea, productive cough with yellow mucus in a client with COPD can indicate an exacerbation or infection, requiring immediate intervention. A: Orientation is not an urgent concern. B: Restlessness can be due to various reasons and doesn't necessarily indicate an emergency. C: Pupillary reactivity is not relevant to COPD management.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (A) may not guarantee accurate communication. Familiarizing with sign language (C) may not be sufficient for complex medical discussions. Using a board with pictures (D) may not be effective for detailed conversations.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample.
- B. Check the client's vital signs.
- C. Stop the infusion.
- D. Administer oxygen to the client.
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client's symptoms suggest a transfusion reaction, which could be life-threatening. Stopping the infusion is the priority to prevent further harm. Checking vital signs can wait, as immediate action is needed. Collecting a urine sample is not urgent in this situation. Administering oxygen is not indicated unless the client shows signs of respiratory distress, which is not mentioned in the scenario.