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 D
Explanation
The nurse should advise the patient with heart failure to limit or avoid canned soups and sauces because they are high in sodium, which can cause fluid retention and worsen cardiac function.Sodium intake should be restricted to less than 2 g per day for patients with heart failure.
Choice A is wrong because fresh fruits and vegetables are good sources of potassium, magnesium, and fiber, which are beneficial for heart health.Potassium and magnesium help regulate fluid and electrolyte balance, and fiber helps lower cholesterol and blood pressure.
Choice B is wrong because whole grains and cereals are also rich in fiber, as well as complex carbohydrates, which provide energy and prevent rapid fluctuations in blood glucose levels.Whole grains and cereals may also contain phytochemicals that have antioxidant and anti-inflammatory effects.
Choice C is wrong because lean meats and poultry are low in saturated fat and cholesterol, which can contribute to atherosclerosis and coronary artery disease. Lean meats and poultry provide protein, which is essential for tissue repair and wound healing.Protein intake should be adequate but not excessive for patients with heart failure, as too much protein can increase the workload of the kidneys.
Correct Answer is ["A","B","C","D"]
Explanation
Nifedipine is a calcium channel blocker that lowers blood pressure by relaxing the blood vessels and reducing the workload of the heart.
The following instructions should be included in the teaching:
• Avoid drinking alcohol while taking this medication.Alcohol can increase the risk of side effects such as dizziness, flushing, headache, and low blood pressure.
• Monitor your blood pressure and pulse regularly.This will help to evaluate the effectiveness of the medication and detect any abnormal changes.Normal blood pressure for adults is less than 130/80 mm Hg and normal pulse rate is 60 to 100 beats per minute.
• Report any swelling in your ankles or feet to your provider.This can be a sign of fluid retention or heart failure, which are possible complications of nifedipine.
• Do not stop taking this medication abruptly.This can cause a rebound increase in blood pressure and chest pain.The dose should be tapered gradually under the supervision of the provider.
Choice E is wrong because chewing or crushing the sustained-release tablet can cause too much of the drug to be released at once, which can lead to overdose or severe side effects.
The tablet should be swallowed whole with a glass of water.
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