A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Inform the client that this drug combination is most effective if the ginkgo biloba is taken twice daily.

Inform the client that memory problems following valve replacement surgery are common, but temporary.

Instruct the client that ginkgo biloba interacts with anticoagulant drugs and then check for bruising or bleeding.

Instruct the client to keep a record of episodes of forgetfulness or memory disturbances to monitor effectiveness.

Answer and Explanation

The Correct Answer is C

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

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Correct Answer is ["A","D","E"]

Explanation

A. Immobility can lead to pressure ulcers due to prolonged pressure on bony prominences.
B. Polyuria is not a common complication of immobility.
C. Diarrhea is not typically associated with immobility; constipation is more common.
D. Immobility can cause contractures of the extremities due to muscle shortening and tightening.
E. Crackles in the lungs can occur due to fluid accumulation and reduced lung expansion associated with immobility.

A. Apply petroleum jelly to the client's lips after oral care. B. Use the thumb and index finger to keep the client's mouth open. C. Use a stiff toothbrush to clean the client's teeth. D. Turn the client on his side before starting oral care.

Correct Answer is D

Explanation

A. Petroleum jelly can be applied, but it is not the priority action.
B. Using the thumb and index finger to keep the client's mouth open can be unsafe and uncomfortable.
C. A soft toothbrush should be used to prevent injury to the oral mucosa.
D. Turning the client on his side reduces the risk of aspiration during oral care.

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A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

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