A nurse is reinforcing discharge teaching for a client who will be taking warfarin (Coumadin) at home. Which of the following statements indicates that the client understands the effects of this medication?
To be sure to eat foods with lots of vitamin K.
Not to take aspirin for my headaches.
That it's okay to have a couple of glasses of wine with dinner.
To use my electric razor for shaving.
The Correct Answer is B
Choice A : While vitamin K is essential for normal blood clotting, warfarin works by blocking the action of vitamin K. Therefore, clients taking warfarin should maintain a consistent intake of vitamin K-rich foods to avoid fluctuations in their response to the medication. Inconsistent vitamin K intake can affect the effectiveness of warfarin. The nurse should educate the client to consume a consistent amount of vitamin K-containing foods rather than emphasizing "lots" of vitamin K.
Choice B : Warfarin is an anticoagulant that increases the risk of bleeding. Taking aspirin (another blood-thinning medication) along with warfarin can further enhance this risk. The nurse should emphasize that clients should avoid taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) without consulting their healthcare provider while on warfarin therapy.
Choice C : Alcohol can interact with warfarin and increase the risk of bleeding. Clients should be advised to limit alcohol consumption while taking warfarin. The nurse should educate the client that alcohol intake should be moderate and consistent, rather than encouraging wine consumption.
Choice D :While it is essential to minimize the risk of cuts and bleeding, the use of an electric razor is not specific to warfarin therapy. Clients should be cautious with any sharp objects, including razors, to prevent bleeding. The nurse should provide general safety instructions for shaving, but this choice does not directly relate to warfarin effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Assisting the client into a standing position is part of the process for checking orthostatic hypotension, but it is not the first action to take. The initial measurement should be taken while the client is supine to establish a baseline blood pressure before any position changes.
Choice B reason : Determining the client's blood pressure 1 minute after each position change is important for diagnosing orthostatic hypotension, but it follows after the initial supine measurement. This step is to observe changes in blood pressure that may indicate orthostatic hypotension.
Choice C reason : Placing the client in a sitting position is another step in the process of checking for orthostatic hypotension. However, it is not the first action. The nurse should first measure the blood pressure in the supine position, then sitting, and finally standing.
Choice D reason : This is the correct first action. Checking the client's blood pressure in a supine position provides a baseline measurement. After this, the nurse can compare the blood pressure readings after the client sits and stands to identify any significant drops that would indicate orthostatic hypotension.
Correct Answer is D
Explanation
Choice A reason: The PR interval, which is the time from the onset of atrial depolarization (beginning of the P wave) to the onset of ventricular depolarization (beginning of the QRS complex), normally ranges from 0.12 to 0.20 seconds. A PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.
Choice B reason: The QT interval represents the total time for ventricular depolarization and repolarization. The normal QT interval varies based on heart rate and gender but is typically less than half of the R-R interval in a normal heart rhythm. Therefore, a QT interval equal to the R-R interval is abnormally prolonged, which may suggest other conditions but is not a specific indicator of acute myocardial infarction.
Choice C reason: The QRS complex reflects ventricular depolarization and normally ranges from 0.06 to 0.10 seconds. A QRS interval of 0.08 second is within the normal range and does not suggest an acute myocardial infarction.
Choice D reason: ST segment elevation is a critical finding in the diagnosis of acute myocardial infarction. The ST segment should be at the isoelectric line; elevation above this line is indicative of myocardial injury and is a key diagnostic criterion for ST-elevation myocardial infarction (STEMI). An elevated ST segment is often seen in the early stages of an acute myocardial infarction and requires immediate medical attention.
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