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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["48"]
Explanation
To calculate the amount of gentamicin the nurse should administer in milliliters (mL) for a client who weighs 210 lb, we can use the following steps:
Given:
Client's weight: 210 lb
Gentamicin dose: 5 mg/kg
Available concentration: 10 mg/mL
Step 1: Convert the client's weight from pounds (lb) to kilograms (kg)
Client's weight in kg = Client's weight in lb / 2.2
Client's weight in kg = 210 lb / 2.2
Client's weight in kg ≈ 95.45 kg
Step 2: Calculate the total dose of gentamicin required
Total dose = Client's weight in kg × Gentamicin dose
Total dose = 95.45 kg × 5 mg/kg
Total dose = 477.25 mg
Step 3: Calculate the volume of gentamicin to be administered in mL
Volume = Total dose / Concentration
Volume = 477.25 mg / 10 mg/mL
Volume ≈ 47.725 mL
Rounding to the nearest whole number:
Volume ≈ 48 mL
Therefore, the nurse should administer approximately 48 mL of gentamicin via intermittent IV bolus to the client who weighs 210 lb.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because a dry cough is not a common or serious side effect of hydralazine. A dry cough is more likely to occur with angiotensin-converting enzyme (ACE) inhibitors, which are another class of antihypertensive drugs.
Choice B reason: This is incorrect because hydralazine does not cause a low heart rate. In fact, hydralazine can cause a reflex increase in heart rate as a result of lowering the blood pressure. This is why hydralazine is often given with a beta-blocker, which can slow down the heart rate.
Choice C reason: This is incorrect because hydralazine does not interact with birth control. However, the nurse should advise the client to use effective contraception while taking hydralazine, as this medication can cause fetal harm if used during pregnancy.
Choice D reason: This is correct because hydralazine can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, fainting, and falls. The nurse should instruct the client to avoid getting up too quickly and to ask for assistance if needed.
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