A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching?
I eat a green salad every night with dinner.
I take this medication at the same time each day.
I have started taking ginger root to treat my joint stiffness.
I had my INR checked three weeks ago.
The Correct Answer is C
Choice A reason: Eating a green salad every night with dinner is not the statement that indicates a need for further teaching. This is a consistent and balanced dietary choice for the client, as long as the amount of vitamin K in the salad is not excessive or variable. Vitamin K is a nutrient that helps the blood to clot and can interfere with the action of warfarin, which is an anticoagulant that inhibits the formation of blood clots. The client should avoid sudden changes in their intake of vitamin K and inform the provider of any dietary modifications.
Choice B reason: Taking this medication at the same time each day is not the statement that indicates a need for further teaching. This is a correct and important instruction for the client, as it helps to maintain a steady and effective level of warfarin in the blood. Warfarin has a narrow therapeutic range and requires frequent monitoring and dose adjustment. The client should take the medication as prescribed and avoid missing or skipping doses.
Choice C reason: Starting to take ginger root to treat joint stiffness is the statement that indicates a need for further teaching. This is a risky and potentially harmful herbal supplement for the client, as it can interact with warfarin and increase its anticoagulant effect. Ginger root has antiplatelet and fibrinolytic properties, which can inhibit the formation of blood clots and enhance the breakdown of fibrin, a protein that stabilizes blood clots. Taking ginger root with warfarin can increase the risk of bleeding and bruising and alter the international normalized ratio (INR), which is a measure of the blood's clotting ability. The client should avoid taking ginger root and other herbal supplements without consulting the provider.
Choice D reason: Having the INR checked three weeks ago is not the statement that indicates a need for further teaching. This is a reasonable and appropriate frequency for the client, depending on their stability and response to warfarin therapy. The INR is a blood test that measures the time it takes for the blood to clot and indicates the effectiveness of warfarin. The target INR range for most clients is 2 to 3, but it may vary depending on the indication and the risk of bleeding. The client should have their INR checked regularly and follow the provider's orders and the protocol for dose adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Blurred vision is not a common or serious side effect of simvastatin, as it does not affect the eyes or the vision. Blurred vision may be caused by other factors, such as diabetes, hypertension, or eye disorders.
Choice B reason: Orthostatic hypotension is not a common or serious side effect of simvastatin, as it does not affect the blood pressure or the vascular tone. Orthostatic hypotension may be caused by other factors, such as dehydration, anemia, or medication interactions.
Choice C reason: Urinary retention is not a common or serious side effect of simvastatin, as it does not affect the urinary tract or the bladder function. Urinary retention may be caused by other factors, such as prostate enlargement, infection, or nerve damage.
Choice D reason: Muscle weakness is a common and serious side effect of simvastatin, as it can indicate muscle damage or rhabdomyolysis. Rhabdomyolysis is a life-threatening condition that causes the breakdown of muscle tissue and the release of myoglobin into the bloodstream, which can lead to kidney failure. Muscle weakness may be accompanied by muscle pain, tenderness, or dark urine. The nurse should monitor the client's creatine kinase (CK) levels and report any signs of muscle damage to the provider.
Correct Answer is B
Explanation
Choice A - Catheter Occlusion: This occurs when the catheter is blocked, preventing the flow of fluids or medication. It is usually indicated by difficulty in flushing the catheter or a slow drip rate¹. However, it does not typically cause a gurgling sound.
Choice B - (Catheter migration) is correct because when a central venous catheter (CVC) migrates from its original position, the tip can enter a smaller vein or a different location where turbulence occurs. This may cause the client to hear a gurgling or bubbling sound, especially during infusion or with position changes. Migration can happen due to coughing, movement, or changes in pressure, and it doesn’t necessarily involve the catheter being visibly out of place
Choice C - (Catheter dislodgment) is incorrect because dislodgment typically refers to the catheter being partially pulled out of the insertion site. This would be more likely to cause external signs like visible catheter movement or fluid leakage at the insertion site, rather than internal gurgling sounds. Gurgling is more associated with internal changes in catheter position, as seen with migration.
Choice D - Catheter Rupture: This is a break or tear in the catheter. It can cause serious complications, including infection and embolism. However, a gurgling sound is not a typical symptom of a catheter rupture¹.
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