A nurse is assisting in the education of a group of clients about the contraindications of warfarin therapy. Which of the following statements is appropriate to include in the instructions?

"Clients who have rheumatoid arthritis should not take warfarin."

"Clients who have diabetes mellitus type 1 should not take warfarin"

"Clients who have hypertension should not take warfarin"

"Clients who are pregnant should not take warfarin"

Answer and Explanation

The Correct Answer is D

A) "Clients who have rheumatoid arthritis should not take warfarin":
Rheumatoid arthritis itself is not a contraindication for warfarin therapy. However, close monitoring is required due to potential interactions with medications used to treat rheumatoid arthritis and the increased risk of bleeding associated with both conditions.

B) "Clients who have diabetes mellitus type 1 should not take warfarin":
Type 1 diabetes mellitus is not a contraindication for warfarin therapy. However, diabetes increases the risk of complications such as peripheral vascular disease, which may necessitate careful monitoring of INR levels and adjustments to warfarin dosage.

C) "Clients who have hypertension should not take warfarin":
Hypertension alone is not a contraindication for warfarin therapy. However, hypertension is a risk factor for cardiovascular diseases that may require anticoagulation therapy. Close monitoring of blood pressure and potential interactions with antihypertensive medications is essential.

D) "Clients who are pregnant should not take warfarin":
Pregnancy is a contraindication for warfarin therapy due to its teratogenic effects, which can cause fetal harm or birth defects. Pregnant clients requiring anticoagulation therapy may be prescribed alternative medications that are safer during pregnancy, under the guidance of a healthcare provider.

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Correct Answer is D

Explanation

A) Dyspnea:
Diphenhydramine primarily addresses allergic reactions such as urticaria (hives) rather than respiratory symptoms like dyspnea associated with blood transfusion reactions.

B) Fever:
The administration of diphenhydramine during blood transfusions is aimed at mitigating allergic reactions, particularly urticaria, rather than fever as a symptom.

C) Low-back pain:
Diphenhydramine is not indicated for preventing or managing low-back pain, which is not typically associated with allergic reactions to blood transfusions.

D) Urticaria:
Diphenhydramine is administered to prevent or reduce symptoms of allergic reactions, particularly urticaria (hives), which can occur during blood transfusions due to immune responses to transfused blood components.

A. Vomiting B. Flushing C. Dyspnea D. Bradycardia

Correct Answer is C

Explanation

A) Vomiting:
Vomiting can occur postoperatively due to various reasons such as anesthesia, medications, or surgical stress. While vomiting should be monitored closely for dehydration and electrolyte imbalance, it is not typically an early sign of circulatory overload.

B) Flushing:
Flushing, or skin redness and warmth, can occur due to vasodilation from anesthesia or medications. It is not specific to circulatory overload unless accompanied by other signs such as dyspnea, elevated blood pressure, and fluid retention.

C) Dyspnea:
Dyspnea, or difficulty breathing, is a critical early sign of circulatory overload in clients receiving IV fluids and blood products. It indicates fluid accumulation in the lungs, necessitating immediate nursing intervention to prevent respiratory distress.

D) Bradycardia:
Bradycardia, or a slow heart rate, can occur postoperatively due to anesthesia effects or vagal stimulation. However, it is not typically associated with circulatory overload, which more commonly manifests with tachycardia as the heart attempts to compensate for increased fluid volume.

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A nurse is assisting in the education of a group of clients about the contraindications of warfarin therapy. Which of the following statements is appropriate to include in the instructions?

Nursing Test Bank

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