A nurse is evaluating a client who has heart failure and is receiving warfarin. Which of the following statements by the client indicates a need for further teaching?
“I will use an electric razor for shaving.”
“I will eat more green leafy vegetables.”
“I will check my stools for blood.”
“I will have my blood drawn regularly.”.
The Correct Answer is B
Choice B is wrong because “I will eat more green leafy vegetables.” This statement indicates a need for further teaching because green leafy vegetables are high in vitamin K, which can antagonize the effects of warfarin and increase the risk of clotting. The client should be advised to maintain a consistent intake of vitamin K and avoid sudden changes in their diet.
Choice A is wrong because using an electric razor for shaving is a safe practice for a client who is receiving warfarin, as it reduces the risk of bleeding from cuts or nicks.
Choice C is wrong because checking stools for blood is an important measure for a client who is receiving warfarin, as it can indicate gastrointestinal bleeding, which is a serious adverse effect of the medication.
Choice D is wrong because having blood drawn regularly is necessary for a client who is receiving warfarin, as it allows the monitoring of the international normalized ratio (INR), which reflects the degree of anticoagulation and guides the dosage adjustment of the medication.
The normal range for INR for a client who is receiving warfarin is 2 to 3, unless otherwise specified by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client has a blood pressure of 120/78 mm Hg. This indicates that the medication is effective because it lowers the blood pressure below the hypertensive levels.In adults 60 years of age or older, this is typically defined as a systolic pressure below 150 mm Hg and a diastolic pressure below 90 mm Hg.
Choice A is wrong because the client has no edema in the lower extremities. This is not a specific outcome of lisinopril, an angiotensin II receptor blocker (ARB). Edema can be caused by many factors, such as heart failure, kidney disease, or venous insufficiency. Lisinopril does not directly affect fluid retention or edema.
Choice B is wrong because the client has a urine output of 30 mL/hr. This is a low urine output that may indicate dehydration, kidney impairment, or urinary obstruction. Lisinopril is expected to increase urine output by reducing the blood pressure and improving the renal blood flow.
Choice D is wrong because the client has a serum creatinine level of 1.2 mg/dL. This is a high serum creatinine level that may indicate kidney damage or reduced kidney function. Lisinopril is expected to lower the serum creatinine level by preventing the progression of kidney disease and protecting the kidney from further injury.
Normal ranges of urine output, blood pressure, and serum creatinine are:
• Urine output: 800 to 2000 mL/day or 40 to 80 mL/hr
• Blood pressure: less than 120/80 mm Hg for adults
• Serum creatinine: 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females
Correct Answer is A
Explanation
Mannitol is an osmotic diuretic that increases urine output and decreases intracranial pressure and intraocular pressure. The nurse should check the urine output before giving the medication to ensure adequate renal function and prevent fluid overload and electrolyte imbalance. The normal urine output is 0.5 to 1 mL/kg/hr.
Choice B is wrong because checking the blood pressure is not specific to mannitol administration. Mannitol can cause hypotension or hypertension depending on the fluid status of the client, but this is not the priority action before giving the medication.
Choice C is wrong because checking the blood glucose is not relevant to mannitol administration. Mannitol does not affect blood glucose levels.
Choice D is wrong because checking the oxygen saturation is not related to mannitol administration. Mannitol does not affect oxygen saturation levels.
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