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 enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Obtain the client's vital signs.
- B. Perform a neurologic check.
- C. Turn the client on their side.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: The correct action is to turn the client on their side (Choice C) during a tonic-clonic seizure to prevent aspiration and maintain a clear airway. This position helps saliva or vomit to drain out of the mouth, reducing the risk of choking. Obtaining vital signs (Choice A) and performing a neurologic check (Choice B) can wait until after the seizure is over. Notifying the rapid response team (Choice D) is not necessary for a single seizure unless complications arise.
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom dark at night.
- B. Cover electrical outlets in the client's home with tape.
- C. Hang a monthly calendar in the client's bedroom.
- D. Place a large-face clock in the client's bedroom.
Correct Answer: D
Rationale: The correct answer is D: Place a large-face clock in the client's bedroom. This is important for clients with Alzheimer's disease as they may have difficulty understanding the concept of time. A large-face clock with clear numbers can help the client orient themselves and maintain a sense of time. Keeping the client's bedroom dark at night (A) may actually increase confusion and disorientation. Covering electrical outlets in the client's home with tape (B) is not relevant to caring for a client with Alzheimer's disease. Hanging a monthly calendar in the client's bedroom (C) may be overwhelming and confusing due to the client's cognitive difficulties.
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles
- B. Decreased urine output
- C. Daytime oliguria
- D. Halo vision
Correct Answer: A
Rationale: The correct answer is A: Crackles. Left-sided heart failure causes fluid buildup in the lungs, leading to pulmonary congestion. Crackles are indicative of fluid in the alveoli, a common sign of pulmonary edema in heart failure. Decreased urine output (B), daytime oliguria (C), and halo vision (D) are not specific to left-sided heart failure. Decreased urine output and oliguria are more associated with kidney dysfunction, while halo vision is related to eye conditions like cataracts.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.