A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?
Increase the intake of dark green leafy vegetables while taking warfarin.
Eat two servings of dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.
Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
Avoid eating any foods that contain any vitamin K because it is an antagonist of warfarin.
The Correct Answer is C
Choice A reason: Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.
Choice B reason: Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.
Choice D reason: Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.
Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.
Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.
Correct Answer is ["B","C","D","E"]
Explanation
Choice B is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause portal hypertension, which is an increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can lead to ascites, which is an accumulation of fluid in the abdominal cavity. The nurse should measure and record the abdominal girth daily and report any significant changes.
Choice C is correct because reporting serum albumin and globulin levels is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can impair the synthesis of proteins, such as albumin and globulin, which are essential for maintaining fluid balance, immune function, and blood clotting. The nurse should monitor and report the serum albumin and globulin levels and administer supplements or transfusions as prescribed.
Choice D is correct because noting signs of bleeding and edema is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause coagulopathy, which is a disorder of blood clotting, due to reduced production of clotting factors and increased consumption of platelets. Coagulopathy can lead to bleeding from various sites, such as the gums, nose, esophagus, stomach, or rectum. The nurse should observe and report any signs of bleeding and apply pressure or bandages as needed. Cirrhosis of the liver can also cause hypoalbuminemia, which is a low level of albumin in the blood, due to decreased synthesis or increased loss of albumin. Hypoalbuminemia can lead to edema, which is swelling caused by fluid retention in the tissues. The nurse should assess and report any signs of edema and elevate the affected limbs or apply compression stockings as indicated.
Choice E is correct because limiting fluid intake to 1500 mL daily is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Fluid restriction can help prevent or reduce ascites and edema by decreasing the fluid load on the circulatory system and the kidneys. The nurse should measure and record the fluid intake and output and educate the client on how to limit their fluid intake.
Choice A is incorrect because providing a diet low in phosphorus is not a specific intervention for a client with cirrhosis of the liver and end stage liver disease. A diet low in phosphorus may be indicated for clients with chronic kidney disease or hyperphosphatemia, but not for clients with cirrhosis of the liver. The nurse should provide a diet that is high in calories, carbohydrates, and protein, but low in sodium, fat, and alcohol for clients with cirrhosis of the liver.
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