Try Naxlex NCLEX-RN (Free-Trial)

A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

You may start taking warfarin while still on Heparin when you are getting ready be discharged home

You will need to have your aPTT monitored frequently while on Warfarin

Use a soft-bristled toothbrush and avoid brushing too aggressively

You should replace straight razors with an electric shaver to avoid cuts

Increase foods high in vitamin K like dark green leafy vegetables, while taking

Answer and Explanation

Correct Answer : A,C,D

The correct answers are:

A. You may start taking warfarin while still on heparin when you are getting ready to be discharged home.

Warfarin takes several days to reach therapeutic levels, so patients often overlap with heparin until the INR (International Normalized Ratio) reaches the target range (typically 2.0-3.0 for most conditions).

C. Use a soft-bristled toothbrush and avoid brushing too aggressively.

Warfarin increases the risk of bleeding, so using a soft toothbrush helps prevent gum bleeding.

D. You should replace straight razors with an electric shaver to avoid cuts.

Since warfarin thins the blood, small cuts can lead to excessive bleeding. An electric shaver reduces the risk of accidental cuts.

B. You will need to have your aPTT monitored frequently while on Warfarin. (Incorrect)

Warfarin is monitored using INR and PT (Prothrombin Time), not aPTT.
aPTT (Activated Partial Thromboplastin Time) is used to monitor heparin therapy, not warfarin.

E. Increase foods high in vitamin K like dark green leafy vegetables while taking Warfarin. (Incorrect)

Vitamin K counteracts warfarin's effects, so patients should keep their vitamin K intake consistent rather than increasing it.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Wear a HEPA/N95 mask while providing care to the client:
Tuberculosis (TB) is a highly contagious airborne disease, and healthcare workers caring for patients with active TB must wear a HEPA/N95 mask to protect themselves from inhaling the bacteria. These specialized masks filter out airborne particles, including Mycobacterium tuberculosis, which can be spread through droplets when the patient coughs, sneezes, or talks. Wearing an N95 mask is an essential part of airborne precautions in the care of TB patients.

B) Instruct the nursing assistant to wear a surgical mask when entering the client's room:
A surgical mask does not offer adequate protection against airborne pathogens like the tuberculosis bacteria. While surgical masks can block large droplets, they do not filter out smaller, airborne particles, such as those from TB. N95/HEPA masks are necessary for anyone entering the room of a patient with active tuberculosis, including nursing assistants, to ensure they are protected from inhaling infectious particles.

C) Ensure the client is in a positive pressure room:
A positive pressure room is typically used for patients who are immunocompromised, such as those with neutropenia or undergoing organ transplants, to prevent infection from the environment. However, negative pressure rooms are required for patients with airborne diseases like tuberculosis. A negative pressure room ensures that air flows into the room but does not leave, containing any airborne pathogens and preventing their spread to other areas of the facility.

D) Have the client wear a HEPA/N95 mask when outside of their room:
If the client with active tuberculosis needs to leave their room for medical procedures or testing, they should wear a HEPA/N95 mask to prevent spreading the bacteria to others through airborne transmission. This helps limit exposure to other individuals, as TB can be transmitted by airborne particles.

A. An area of non-blanchable redness on inner skin B. An open wound with visible adipose tissue C. An area of shallow broken skin with blistering D. Deep purple discoloration over intact skin

Correct Answer is C

Explanation

A. An area of non-blanchable redness on inner skin:
A stage II pressure injury is characterized by partial-thickness skin loss involving the epidermis and/or dermis. It may present as a shallow, open wound or blister. However, non-blanchable redness, which suggests a stage I pressure injury, is not consistent with stage II, as stage II involves more significant skin damage, including blistering or broken skin.

B. An open wound with visible adipose tissue:
This description is more characteristic of a stage III pressure injury, which involves full-thickness skin loss extending into the subcutaneous tissue, revealing adipose tissue. Stage II pressure injuries, on the other hand, are partial-thickness and do not expose underlying structures such as adipose tissue.

C. An area of shallow broken skin with blistering:
Stage II pressure injuries are defined by partial-thickness skin loss, which can present as a shallow open wound or blister. This description accurately fits the characteristics of a stage II pressure injury, where the skin is damaged but the full-thickness layers are not yet compromised.

D. Deep purple discoloration over intact skin:
This is indicative of a stage I pressure injury, which involves intact skin with non-blanchable redness or discoloration. Stage II injuries involve skin breakdown and would not present with intact skin or deep purple discoloration. This description is more aligned with the early stages of pressure injury development, not stage II.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with active tuberculosis. Which of the following intervention are appropriate for this client?

Correct Answer is A

Explanation

You are assessing a client admitted from a long-term care facility. When noting a stage Il pressure injury on the client's coccyx, which of the following would you expect?

Correct Answer is C

Explanation

A client with a history of hypertension who was prescribed Captopril complains of a chronic dry cough for the past several weeks. Which of the following actions should the nurse recommend?

A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

The nurse is caring for a client with human immunodeficiency virus (HIV) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client’s stage of the disease?

Which of the following is the priority intervention for preventing a fat embolism in a client experiencing an open femur fracture?

The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

A nurse is providing teaching to a patient with chronic venous insufficiency. Which of the following should be included in the teaching plan? (Select all that apply.)

The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?