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 interact with this medication?
- A. Orange juice.
- B. Kale.
- C. Beef stew.
- D. Yogurt.
Correct Answer: B
Rationale: The correct answer is B: Kale. Kale is high in vitamin K, which can interfere with the anticoagulant effects of warfarin by increasing the clotting factors in the blood, leading to a decreased INR. It is important for patients on warfarin to maintain a consistent intake of vitamin K-rich foods to ensure their INR remains within the therapeutic range. Orange juice (A), beef stew (C), and yogurt (D) do not significantly interact with warfarin. A summary of why they are incorrect: Orange juice does not have a direct interaction with warfarin. Beef stew does not contain significant amounts of vitamin K. Yogurt is not a high vitamin K food.
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A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk to you before you leave.
- B. I can contact the occupational therapist to schedule a home visit.
- C. Contact your pharmacy to inquire about a different medication.
- D. You should ask your provider to prescribe a cheaper medication.
Correct Answer: A
Rationale: The correct answer is A because the nurse should address the client's financial concerns by offering a social worker to assist with resources. This option demonstrates holistic care and supports the client's well-being beyond the medical aspect. Option B is irrelevant as it does not address the medication affordability issue. Option C puts the burden on the client to find a solution. Option D is not appropriate as the client may not feel comfortable asking for a cheaper medication directly.
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the feet.
- B. Keep the client's knees in a flexed position while they are in bed.
- C. Massage the client's legs every 4 hr while they are awake.
- D. Limit the client's fluid intake to 2
Correct Answer: A
Rationale: Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood instead of a friend.
- B. This surgery has minimal blood loss so you will not require a transfusion.
- C. You can donate your own blood a few weeks prior to this surgery.
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the correct answer because autologous blood donation involves donating your own blood before surgery to be transfused back to you if needed. This reduces the risk of transfusion reactions and ensures a compatible blood match. Option A is incorrect because family members are not typically required to donate blood for surgery. Option B is incorrect as total hip arthroplasty can involve significant blood loss. Option D is incorrect as even with screened donor blood, transfusion reactions can still occur.
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Phlebitis
Correct Answer: B
Rationale: The correct answer is B: Infection. When IV tubing is kinked, it can lead to a backflow of urine from the catheter into the tubing, increasing the risk of contamination and subsequent urinary tract infection. Additionally, when the urinary catheter bag is lying next to the client in bed, there is a higher chance of accidental contamination. Infections can lead to serious complications and require prompt intervention. Neurogenic bladder (A) is related to nerve damage affecting bladder control, not directly related to the current situation. Skin breakdown (C) may occur due to prolonged contact with urine but is not the immediate concern here. Phlebitis (D) is inflammation of a vein, not directly linked to the urinary catheter issue.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.