A nurse is reviewing the medical history of a client who asks about the use of warfarin.
The nurse should identify which of the following findings as a contraindication for the administration of this medication?

Recent myocardial infarction.

Recent eye surgery.

Thrombophlebitis.

Breast cancer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.

Choice B rationale:

Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.

Choice C rationale:

Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.

Choice D rationale:

Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.

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Correct Answer is C

Explanation

Choice A rationale:

Using a 12-point font when printing written materials is helpful for readability, especially for individuals with visual impairments. However, this action alone does not necessarily promote meaningful learning. The content and presentation style are equally important.

Choice B rationale:

Presenting information using abstract concepts can be confusing, especially for older adults. Using concrete examples and simple language facilitates better understanding. Abstract concepts are more challenging to grasp, especially for individuals who might be experiencing cognitive decline.

Choice C rationale:

Connecting new information with the client's past experiences enhances learning and retention. Relating new knowledge to familiar situations or memories helps create cognitive associations, making it easier for the client to understand and remember the information. This technique is particularly effective in promoting learning among older adults.

Choice D rationale:

Speaking loudly when addressing the client is unnecessary and can be perceived as rude or patronizing. Clear and audible speech is essential, but shouting or raising the volume excessively is not respectful and does not enhance the learning experience.

A. Maintain bed elevation at 20 degrees. B. Flush the tubing with 30 mL of water every 4 hr. C. Check for gastric residual every 12 hr. D. Place enough formula in the container to last 18 hr.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees.This is to prevent aspiration of the feeding solution into the lungs.

Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice.This helps to maintain the patency of the feeding tube and prevent clogging.

Choice C rationale: Checking for gastric residual every 12 hours is not sufficient.For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours.This helps to assess tolerance to the feeding and prevent complications such as aspiration.

Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended.For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.

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A nurse is reviewing the medical history of a client who asks about the use of warfarin.The nurse should identify which of the following findings as a contraindication for the administration of this medication?

Nursing Test Bank

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A nurse is reviewing the medical history of a client who asks about the use of warfarin.
The nurse should identify which of the following findings as a contraindication for the administration of this medication?