Nokea
The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I eat a salad with spinach every day.
- B. I take ibuprofen for my headaches.
- C. I drink a glass of red wine with dinner.
- D. I walk for 30 minutes every morning.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.
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A client with signs of increased intracranial pressure (ICP).
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
- A. Encourage coughing and deep breathing to prevent pneumonia.
- B. Suction the airway every 2 hours to remove secretions.
- C. Position the client in the prone position to promote venous return.
- D. Determine cough reflex and ability to swallow prior to administering PO fluids.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
Which of the following positions is best for a client with preeclampsia who is in labor?
- A. Left Sims
- B. High Fowler's
- C. Trendelenburg
- D. Supine
Correct Answer: A
Rationale: The left Sims position promotes placental perfusion and reduces pressure on the vena cava in preeclampsia, improving maternal and fetal outcomes. Other positions are less optimal.
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
- A. Tell the client to sit down and get control of herself
- B. Leave the room until she regains control
- C. Whisper to her that everything will be all right
- D. Attend to her behavior and direct her to a quiet area
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.