The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities.

What should be the nurse’s initial action?

Hold the warfarin until the next day’s dose and notify the laboratory.

Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted.

Administer the daily dose of warfarin as these are the expected side effects of the medication.

Hold the warfarin until the healthcare provider is notified of the assessment findings.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.

Choice B rationale

Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.

Choice C rationale

Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.

Choice D rationale

The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.

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Correct Answer is C

Explanation

Choice A rationale

A fasting blood glucose level of 135 mg/dL is above the diagnostic threshold for diabetes. However, it is not the exact threshold value.

Choice B rationale

A fasting blood glucose level of 140 mg/dL is significantly above the diagnostic threshold for diabetes.

Choice C rationale

A fasting blood glucose level of 126 mg/dL or higher on two separate tests indicates diabetes.

Choice D rationale

A fasting blood glucose level of 145 mg/dL is significantly above the diagnostic threshold for diabetes.

A. The client will verbalize an understanding of appropriate foot care measures by discharge. B. The client will verbalize the importance of taking anti-platelet medications by discharge. C. The client will discuss exercises that promote healing of wounds prior to discharge. D. The client will recognize the need for an amputation in the near future.

Correct Answer is A

Explanation

Choice A rationale

The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.

Choice B rationale

While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.

Choice C rationale

Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.

Choice D rationale

Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.

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The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is aware that the diagnostic level of a fasting blood glucose for a client with diabetes is:

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet. What is an expected outcome to include in the care plan?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

A patient recovering from aorto-femoral bypass surgery has developed edema, severe pain, paresthesia, and tightness of the operative limb. The nurse recognizes that what post-operative complication is most likely causing the patient’s symptoms?

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A client diagnosed with Raynaud’s disease is experiencing severe pain and spasms in the fingers and toes of their hands. What advice should the nurse include in the discharge instructions for this client?

A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?

The nurse explains to a patient diagnosed with diabetes mellitus that the major benefit of frequent self-monitoring of blood glucose is that:

What clinical manifestation should the nurse assess for in a patient with uncontrolled diabetes mellitus and ketoacidosis?

The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities.

What should be the nurse’s initial action?