Try Naxlex NCLEX-RN (Free-Trial)

The client is prescribed aspirin and warfarin. Based on side effects of both medications, the nurse identifies "Risk for bleeding" as a nursing diagnosis for this client. What outcome is appropriate for this nursing diagnosis?

The client will remain free from visible bleeding, bruising, and signs of internal bleeding (tachycardia and hypotension) during this shift.

The client will verbalize understanding of dietary restrictions while on warfarin and provide examples of foods that contain vitamin K during this shift

The client will state their pain level is less than 4 on a 0-10 pain scale during aspirin therapy.

The client will remain free from any signs and symptoms of deep vein thrombosis,

Answer and Explanation

The Correct Answer is A

A) The client will remain free from visible bleeding, bruising, and signs of internal bleeding (tachycardia and hypotension) during this shift: This is the most appropriate outcome for the "Risk for bleeding" nursing diagnosis. Since both aspirin and warfarin are anticoagulants, they increase the client's risk of bleeding. The priority is to monitor for and prevent any signs of visible bleeding, bruising, or more serious internal bleeding, which could manifest as tachycardia or hypotension. This outcome directly addresses the client's safety by focusing on detecting and preventing bleeding complications.

B) The client will verbalize understanding of dietary restrictions while on warfarin and provide examples of foods that contain vitamin K during this shift: While this is an important goal for clients on warfarin (because vitamin K can interfere with the effectiveness of warfarin), it is not the most immediate concern in the context of the "Risk for bleeding" diagnosis. Dietary restrictions should be discussed but are not as time-sensitive or directly related to the prevention of bleeding in the short term, especially during this shift.

C) The client will state their pain level is less than 4 on a 0-10 pain scale during aspirin therapy: While managing pain is important, this outcome does not directly address the risk for bleeding associated with both aspirin and warfarin therapy. The priority nursing concern here is preventing bleeding, not pain management during aspirin therapy.

D) The client will remain free from any signs and symptoms of deep vein thrombosis (DVT): While preventing DVT is important for patients on anticoagulant therapy, the focus of this nursing diagnosis is on the risk of bleeding, not thrombosis. Therefore, this outcome is not as relevant to the immediate concerns related to the prescribed medications (aspirin and warfarin).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Cerebral Vascular Accident (CVA): While a history of a CVA (stroke) is important to consider when prescribing medications, ondansetron is not contraindicated for clients with a history of CVA. The nurse would need to assess the client’s overall neurological status and risk factors but this condition is not an immediate concern for ondansetron use.

B) Depression: Ondansetron is not typically contraindicated in patients with depression. However, the nurse should be mindful of the potential for interactions with other medications the client may be taking for depression, but there is no direct contraindication between ondansetron and depression itself.

C) Glaucoma: This is the most concerning finding. Ondansetron can increase the risk of complications in clients with glaucoma, particularly narrow-angle glaucoma. Ondansetron has some serotonin receptor-blocking properties that can cause dilation of the pupil, which could increase intraocular pressure in clients with glaucoma. Therefore, this condition would require careful monitoring, and the nurse would need to consult with the healthcare provider before administering ondansetron to a client with glaucoma.

D) Congestive Heart Failure (CHF): While patients with CHF need to be monitored for fluid balance, ondansetron is not contraindicated in clients with CHF. The primary concern in these patients would be potential fluid retention or electrolyte imbalances, but this is generally not a direct concern for the administration of ondansetron itself.

Correct Answer is ["250"]

Explanation

Identify the total volume:

The client is ordered to receive 1000 mL of 0.9% saline.

Identify the infusion time:

The infusion time is 4 hours.

Set up the calculation:

We need to find out the IV pump rate in mL/hr. We can use the following formula:

(Total volume) / (Infusion time) = IV pump rate

4. Plug in the values and calculate:

(1000 mL) / (4 hours) = 250 mL/hr

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The client is prescribed aspirin and warfarin. Based on side effects of both medications, the nurse identifies "Risk for bleeding" as a nursing diagnosis for this client. What outcome is appropriate for this nursing diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is prescribed ondansetron for nausea. When reviewing the client's medical history, which finding would concern the nurse?

Correct Answer is C

Explanation

A client is ordered to receive 1000ml of 0.9% saline over 4 hours. At what rate will the nurse set the IV pump in mL/hr? (Enter a number only).

Correct Answer is ["250"]

Explanation

The nurse is caring for client with liver failure admitted with hepatic encephalopathy, Lactulose is ordered Q2 hours. What assessment finding should the nurse use to best evaluate therapeutic response of the medication?

The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?

A nurse recognizes they administered a medication over one hour when the order dictated the medication be given over 90 minutes. Which should be the first action performed by the nurse?

A client has been diagnosed with an ulcer and will begin taking sucralfate. What information should the nurse include when providing education to the client?

The client receives one dose of 200 mg of a medication. How much drug is in the body at 3 half-lives?

A client is currently receiving chemotherapy and is experiencing nausea and vomiting. What should the nurse teach the client to help reduce the nausea and vomiting?

A nurse assesses the client and determines the client is at risk for infection. Which activity best reflects the planning phase of the nursing process?