A nurse is teaching a client who has DVT and is prescribed warfarin.
Which of the following instructions should the nurse include in the teaching?
Avoid foods that are high in vitamin K
Use an electric razor for shaving
Monitor for signs of bleeding gums
All of the above.
The Correct Answer is D
The correct answer is choice D. All of the above.
The nurse should include the following instructions in the teaching:
• Avoid foods that are high in vitamin K. Vitamin K can lower the effect of warfarin and increase the risk of blood clots. Foods rich in vitamin K are green vegetables, such as lettuce, spinach and broccoli.
• Use an electric razor for shaving. Warfarin can increase the risk of bleeding, so using a sharp blade can cause cuts and bruises.
• Monitor for signs of bleeding gums. Bleeding gums can be a sign of excessive anticoagulation and a potential side effect of warfarin.
Choice A is wrong because avoiding foods that are high in vitamin K is not enough to prevent bleeding complications.
The client should also follow other precautions, such as using an electric razor and monitoring for signs of bleeding gums.
Choice B is wrong because using an electric razor for shaving is not enough to prevent bleeding complications.
The client should also avoid foods that are high in vitamin K and monitor for signs of bleeding gums.
Choice C is wrong because monitoring for signs of bleeding gums is not enough to prevent bleeding complications.
The client should also avoid foods that are high in vitamin K and use an electric razor for shaving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.Warmth and erythema in the affected leg are signs of inflammation and possible infection caused by deep vein thrombosis (DVT), a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs.
The nurse should report this finding to the provider as it may indicate a serious complication.
Choice B is wrong because a negative Homans’ sign, which is the absence of pain in the calf when the foot is dorsiflexed, does not rule out DVT.This sign is unreliable and nonspecific for DVT diagnosis.
Choice C is wrong because decreased calf circumference is not a typical symptom of DVT.In fact, DVT may cause swelling of the affected leg due to impaired blood flow.
Choice D is wrong because pallor and coolness in the affected leg are more indicative of arterial occlusion, which is a blockage of blood flow in an artery, rather than venous occlusion, which is a blockage of blood flow in a vein.
Normal ranges for D-dimer blood test, which measures a substance in the blood that’s released when a blood clot dissolves, are less than 0.5 mcg/mL or 500 ng/mL.High levels of D-dimer may indicate DVT or other conditions that cause blood clots.
Correct Answer is ["C"]
Explanation
The correct answer is choice C. Administer low molecular weight heparin.Low molecular weight heparin is an anticoagulant drug that prevents the formation and growth of blood clots in patients at risk for VTE.It is recommended for patients undergoing hip replacement surgery as a pharmacological prophylaxis.
Choice A is wrong because applying sequential compression devices (SCDs) is not enough to prevent VTE in patients undergoing hip replacement surgery.SCDs are mechanical devices that improve blood flow in the legs by inflating and deflating around them.However, they are not as effective as anticoagulant drugs in reducing the incidence of VTE.
Choice B is wrong because encouraging early ambulation is not enough to prevent VTE in patients undergoing hip replacement surgery.Early ambulation is the act of walking soon after surgery to improve circulation and prevent complications.However, it is not associated with a lower risk of VTE compared to bed rest.
It may also be contraindicated in some patients depending on their surgical and medical conditions.
Choice D is wrong because elevating the affected leg above the level of the heart is not enough to prevent VTE in patients undergoing hip replacement surgery.Elevating the leg may help reduce swelling and pain, but it does not prevent clot formation or propagation.
Choice E is wrong because massaging the affected leg gently is not only ineffective but also harmful for preventing VTE in patients undergoing hip replacement surgery.Massaging the leg may dislodge existing clots and cause them to travel to the lungs, resulting in a life-threatening pulmonary embolism.
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