Which of the following would be included in bleeding precautions for a client taking warfarin? SELECT ALL THAT APPLY

Use soft bristled tooth brush

Report black or bloody bowel movements

Limit all fruits and vegetables

Report coffee ground or bloody emesis

Shave with electric razor instead of razor blade

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Using a soft bristled tooth brush can prevent gum bleeding and irritation that may occur with a hard bristled tooth brush. Gum bleeding can be a sign of excessive anticoagulation and increased risk of bleeding.

Choice B reason: Reporting black or bloody bowel movements is important because it can indicate gastrointestinal bleeding, which can be a serious complication of warfarin therapy. Gastrointestinal bleeding can cause anemia, shock, and even death if not treated promptly.

Choice C reason: Limiting all fruits and vegetables is not necessary for a client taking warfarin. However, some fruits and vegetables, especially those that are high in vitamin K, can interfere with the effect of warfarin and increase the risk of clotting. Vitamin K is found in green leafy vegetables, such as spinach, kale, broccoli, and cabbage, and some fruits, such as avocado, kiwi, and grapes. The client should maintain a consistent intake of vitamin K and avoid sudden changes in their diet.

Choice D reason: Reporting coffee ground or bloody emesis is also important because it can indicate upper gastrointestinal bleeding, which can be another serious complication of warfarin therapy. Upper gastrointestinal bleeding can cause hematemesis, melena, anemia, and hypovolemic shock.

Choice E reason: Shaving with an electric razor instead of a razor blade can prevent skin cuts and bleeding that may occur with a razor blade. Skin cuts and bleeding can be a sign of excessive anticoagulation and increased risk of bleeding.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect because 30 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin has a rapid onset of action and should relieve chest pain within 5 minutes. If not, the client may need another dose or emergency care.

Choice B reason: This is correct because 5 minutes is the appropriate time to reassess a client after administering nitroglycerin sublingual. The nurse should check the client's blood pressure, heart rate, and pain level. If the pain persists, the nurse should follow the protocol for giving another dose or calling for help.

Choice C reason: This is incorrect because 1 hour is too long to wait for reassessing a client with chest pain. Nitroglycerin has a short duration of action and may need to be repeated every 5 minutes for up to 3 doses. Waiting for an hour may put the client at risk of worsening cardiac ischemia or infarction.

Choice D reason: This is incorrect because 15 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin should have an effect within 5 minutes. If the pain is not relieved by then, the client may need another dose or emergency care.

A. Excessive urination B. Excessive thirst C. Diaphoresis D. Atrial fibrillation E. Excessive hunger

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Excessive urination is a sign of hyperglycemia because the body tries to flush out the excess glucose in the blood through the urine. This can also lead to dehydration and electrolyte imbalance.

Choice B reason: Excessive thirst is a sign of hyperglycemia because the body loses fluid and becomes dehydrated due to frequent urination. The thirst mechanism is activated to replenish the fluid loss.

Choice C reason: Diaphoresis is not a sign of hyperglycemia, but rather a sign of hypoglycemia (low blood sugar). Hypoglycemia can cause sweating, shakiness, anxiety, and confusion.

Choice D reason: Atrial fibrillation is not a sign of hyperglycemia, but rather a possible complication of hyperglycemia. Hyperglycemia can damage the blood vessels and the heart, increasing the risk of arrhythmias, such as atrial fibrillation.

Choice E reason: Excessive hunger is a sign of hyperglycemia because the body is unable to use the glucose in the blood for energy. The cells are starved of fuel, and the hunger signal is triggered to stimulate food intake..

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Which of the following would be included in bleeding precautions for a client taking warfarin? SELECT ALL THAT APPLY

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Naxlex Comprehensive Predictor Exams

When should the nurse reassess a client after administering 0.4 mg nitroglycerin sublingual to a client with chest pain?

Correct Answer is B

Explanation

A patient taking somatropin growth hormone needs to be educated on signs and symptoms of hyperglycemia. What will the nurse include in this teaching? SELECT ALL THAT APPLY

Correct Answer is ["A","B","E"]

Explanation

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