An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:
reflex tone
body for bruising
serum creatinine level
prothrombin time
The Correct Answer is D
A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This question is specific to a potential complication of diabetes, but it does not directly assess the patient's understanding of their current health problems or the importance of self-monitoring blood glucose levels.
B. This question is about a specific laboratory result, but it does not assess the patient's understanding of the importance of self-monitoring blood glucose levels.
C. This question assesses the patient's understanding of the importance of self-monitoring blood glucose levels, which is crucial for managing diabetes. By understanding the reasons behind this intervention, the patient is more likely to comply with the treatment plan and make informed decisions about their health.
D. This question is about the logistics of medication management, but it does not assess the patient's understanding of their current health problems or the importance of self-monitoring blood glucose levels.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. This question assesses whether the team member has the appropriate skills, training, and competency to perform the task safely and effectively. Ensuring that the right person is assigned is crucial for quality care and patient safety.
B. This question evaluates whether the task is appropriate to delegate, considering factors such as the complexity of the task, whether it is within the scope of practice for the team member, and if it aligns with the team's responsibilities. Delegating tasks that are outside the scope of the team member’s practice or too complex can lead to errors or suboptimal care.
C. This question examines whether the level of supervision required for the task is appropriate. The nurse must ensure that appropriate oversight is provided to monitor the team member's performance and address any issues that may arise during task execution.
D. This question considers whether the current circumstances or context (such as the patient's condition, the urgency of the task, or environmental factors) are suitable for delegating the task. Certain situations may require direct nursing involvement or special attention, which can affect the appropriateness of delegation.
E. This question evaluates whether the timing of the task is appropriate, considering factors like the urgency of the task, the team member’s current workload, and patient needs. Timing can impact the effectiveness and safety of task completion.
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