Nokea
The client prescribed rivaroxaban (Xarelto), an anticoagulant, is complaining of dark, tarry stool. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Ask the client to provide a stool sample.
- C. Ask the client when the rivaroxaban was last taken.
- D. Assess the client for ecchymotic areas and bleeding.
Correct Answer: A
Rationale: Dark, tarry stool suggests GI bleeding; notifying HCP (A) is first for urgent evaluation. Stool sample (B), last dose (C), and bleeding assessment (D) follow.
You may also like to solve these questions
Which complication of anticoagulant therapy should the nurse teach the client to report to the health-care provider?
- A. Gastric upset.
- B. Bleeding from any site.
- C. Constipation.
- D. Myocardial infarction.
Correct Answer: B
Rationale: Bleeding (B) is a serious anticoagulant complication, requiring HCP notification. Gastric upset (A) and constipation (C) are minor, and MI (D) is unrelated.
Which assessment finding in a client with heart failure indicates pulmonary edema?
- A. Crackles in the lung bases
- B. Dry, nonproductive cough
- C. Bradycardia
- D. Warm, dry skin
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
The client with cardiomyopathy is prescribed a beta-blocker. What is the primary purpose of this medication?
- A. Increase heart rate
- B. Reduce cardiac workload
- C. Prevent blood clots
- D. Remove excess fluid
Correct Answer: B
Rationale: Beta-blockers reduce heart rate and myocardial oxygen demand, decreasing cardiac workload.
Which finding in a client with cardiomyopathy indicates a need for immediate action?
- A. Blood pressure of 130/85 mmHg
- B. New irregular heart rhythm
- C. Mild leg swelling
- D. Fatigue after activity
Correct Answer: B
Rationale: A new irregular heart rhythm may indicate a life-threatening arrhythmia, requiring immediate intervention.
The nurse is teaching a client about home blood pressure monitoring. Which instruction is most important?
- A. Take your blood pressure at the same time each day.
- B. Use a wrist cuff for the most accurate readings.
- C. Sit with your legs crossed during measurement.
- D. Check your blood pressure only when you feel ill.
Correct Answer: A
Rationale: Consistency in timing ensures accurate trending of blood pressure readings.