A nurse is assessing a client who is taking warfarin. Which of the following findings should the nurse identify as the priority to report to the provider?
Fever
Abdominal cramping
Hair loss
Melena
The Correct Answer is D
Melena means that the stool has a dark discoloration. This is a sign of gastrointestinal bleeding and should be reported immediately as it can be a serious complication of warfarin therapy.
A,B,C- Are not related to use of warfarin
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The provider should be consulted as other oral alternative exist. It is important for the nurse to understand his or her role as a client’s advocate. In this, role, she should acknowledge the client’s concerns and address the issues without coercing or threatening the client.
A- This does not respect client’s autonomy
B- This statement is inappropriate as the nurse should not use threats to induce fear
C- This statement fails to appreciate the client’s concerns
Correct Answer is B
Explanation
Hypoglycemia is a potential complication of parenteral nutrition, especially if the infusion rate is too high or if the infusion is interrupted. The nurse should promptly address hypoglycemia by administering IV dextrose, which will help raise the client's blood glucose levels.
A. Discontinuing the infusion may be necessary if the cause of hypoglycemia is related to the parenteral nutrition solution or if the infusion rate needs adjustment. However, the immediate priority is to treat the hypoglycemia by providing a glucose source.
C. Warming the formula to room temperature is not relevant to treating hypoglycemia. Warming the formula might be done for other reasons, such as improving tolerance or reducing discomfort during administration.
D. Obtaining arterial blood gases is not indicated for treating hypoglycemia. Arterial blood gases are typically obtained to assess oxygenation and acid-base balance, not glucose levels.
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