A nurse in a clinic is reviewing teaching about food choices with a client who has recently begun taking warfarin. The nurse should instruct the client to limit consumption of which of the following foods?

Kale

White beans

Cantaloupe

Whole grain bread

Answer and Explanation

The Correct Answer is A

A. Kale: Kale is high in vitamin K, which can counteract the effects of warfarin and reduce its effectiveness. Clients on warfarin are typically advised to limit or maintain a consistent intake of foods high in vitamin K.

B. White beans: White beans are not high in vitamin K and do not need to be limited in a client taking warfarin.

C. Cantaloupe: Cantaloupe is not high in vitamin K and is safe to consume while on warfarin.

D. Whole grain bread: Whole grain bread is not a significant source of vitamin K and does not interfere with warfarin.

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Correct Answer is C

Explanation

A. Call 911 for change in condition: Although a weight gain of 1.8 kg (4 lb) and generalized edema are concerning signs of worsening heart failure, calling 911 is not immediately warranted unless the patient is in acute distress, such as having severe shortness of breath or chest pain.

B. Reinforce the importance of daily weights: Daily weight monitoring is important for managing heart failure, but this is not the priority action. The patient's weight gain indicates fluid retention, which requires immediate evaluation of the effectiveness of diuretic therapy.

C. Ensure the client has been taking their prescribed diuretic: The priority action is to assess whether the patient has been taking their diuretic as prescribed, as non-adherence can lead to fluid retention and worsening heart failure. Ensuring compliance with diuretics and adjusting the dose may be necessary to manage the condition.

D. Document the findings and continue with the visit: While documentation is essential, the nurse must first address the cause of the weight gain and edema by assessing medication compliance and possibly contacting the provider for further instructions.

A. Attach the leads for a 12-lead ECG. B. Initiate oxygen therapy. C. Obtain a blood sample. D. Insert the IV catheter.

Correct Answer is B

Explanation

A. Attach the leads for a 12-lead ECG. While a 12-lead ECG is important in diagnosing chest pain, the client’s oxygenation is a priority and should be addressed before further diagnostics.

B. Initiate oxygen therapy. The priority in this scenario is to address the client's cyanosis and shortness of breath. Oxygen therapy improves oxygen delivery to tissues and should be the first intervention.

C. Obtain a blood sample. Obtaining cardiac enzyme levels is necessary for diagnosing myocardial infarction, but oxygen therapy should be initiated first to address immediate respiratory distress.

D. Insert the IV catheter. Inserting an IV catheter is important for administering fluids and medications, but it is not the most urgent action in the presence of hypoxia.

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Test:	Results:	Reference ranges:
White Blood Cell Count (WBC)	7000/µL	4,000-11,000/µL
Hemoglobin (Hb)	10.2 g/dl	12.0-15.5 g/dL
Hematocrit (Hct)	32%	37-47%
Platelets	250,000/µL	150,000-450,000/µL

Test	Result	Reference range
Sodium (Na):	132	135-145 mmol/L
Potassium (K):	5.8	3.5-5.0 mmol/L
Chloride (Cl):	97	98-106 mmol/L
Creatinine:	1.5	0.6-1.2 mg/dL
Blood Urea Nitrogen (BUN):	40	7-20 mg/dL

A nurse in a clinic is reviewing teaching about food choices with a client who has recently begun taking warfarin. The nurse should instruct the client to limit consumption of which of the following foods?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg, as well as generalized edema, since the last visit 3 days ago. Which of the following actions is a priority for the nurse to take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of coronary heart disease. Which of the following actions should the nurse take? (Select all that apply.)

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