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

Answer and Explanation

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.

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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.

A. sign of respect for the wisdom and expertise of the nurse B. means of communicating his dissatisfaction with his care C. indication that he has no questions regarding the care he is receiving D. expression of discomfort discussing personal matters

Correct Answer is A

Explanation

A. In Korean culture, silence and avoiding eye contact can be seen as signs of respect and deference, especially towards individuals perceived as having authority or expertise. Therefore, the patient's behavior is likely not a sign of dissatisfaction or discomfort, but rather a cultural expression of respect for the nurse.
B. While it is possible for the patient to be dissatisfied with his care, the nurse should not assume this based solely on his behavior. It's important to consider cultural factors and use other communication strategies to assess the patient's needs and concerns.
C. This is not necessarily the case. The patient may simply be uncomfortable speaking up or asking questions in a language that is not his native tongue.
D. While it is possible for the patient to be uncomfortable discussing personal matters, the nurse should not assume this based solely on his behavior. It's important to consider cultural factors and use other communication strategies to assess the patient's needs and concerns.

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An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which questions should the nurse consider before delegating care to another team member? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

While caring for an older Korean patient, the nurse notes that the patient answers questions regarding health history when asked but is otherwise silent and does not maintain eye contact. Being culturally sensitive, the nurse recognizes that the patients actions are most likely a(n):

Correct Answer is A

Explanation

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