Nokea
Why should clients who take warfarin (Coumadin) refrain from food items such as green leafy vegetables and soybeans?
- A. Because the foods contain Vitamin K, which reduces the anti coagulant effect of the medication
- B. Because the foods contain Vitamin K, which increases the anti coagulant effect of the medication
- C. Because the foods help stimulate salivation
- D. Because the foods minimize the volume of food consumption
Correct Answer: A
Rationale: The correct answer is A because green leafy vegetables and soybeans are high in Vitamin K, which counteracts the anticoagulant effect of warfarin. Warfarin works by inhibiting Vitamin K-dependent clotting factors in the liver. By consuming Vitamin K-rich foods, the medication's effectiveness is reduced, leading to an increased risk of blood clot formation. Choices B, C, and D are incorrect because they do not address the specific interaction between Vitamin K and warfarin in affecting coagulation. Choice B suggests the opposite effect of what actually occurs. Choices C and D are irrelevant to the pharmacological mechanism of warfarin.
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A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client’s vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?
- A. Initial assessment
- B. Focused assessment
- C. Time-lapsed reassessment
- D. Emergency assessment
Correct Answer: B
Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes.
A: Initial assessment is conducted upon admission to establish baseline data.
C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period.
D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues.
By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
- A. Fasciculations
- B. Chorea
- C. Atrophy
- D. Neuropathy
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues.
A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care.
B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications.
C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D.
Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.