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The nurse is teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? Select all that apply.
- A. Keep a constant amount of green, leafy vegetables in the diet.
- B. Instruct the client to have regular INR laboratory work done.
- C. Tell the client to go to the hospital immediately for any bleeding.
- D. Inform the client to notify the HCP if having dark, tarry stools.
- E. Encourage the client to avoid all green vegetables.
- F. Have the client take iron orally to prevent bleeding.
Correct Answer: A,B,D
Rationale: Constant green vegetable intake (A), regular INR (B), and reporting tarry stools (D) ensure safe warfarin use. Avoiding all greens (E) is unnecessary, and iron (C) doesn’t prevent bleeding. Immediate hospital for any bleeding (C) is excessive; minor bleeding requires HCP contact.
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The client with peripheral artery disease asks why they need to walk daily. What is the best response?
- A. It strengthens your leg muscles.
- B. It promotes collateral circulation.
- C. It reduces swelling in your legs.
- D. It prevents venous ulcers.
Correct Answer: B
Rationale: Walking stimulates the development of collateral vessels, improving blood flow in peripheral artery disease.
Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?
Correct Answer: 1.5
Rationale: Dose required: 7.5 mg. Available: 5 mg/tablet. 7.5 ÷ 5 = 1.5 tablets. Administer 1.5 tablets (e.g., one whole and one half, if scored).
The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).