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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).

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Correct Answer is A

Explanation

A) 1 x soft bowel movement: This is the correct answer. Psyllium is a bulk-forming laxative that helps to relieve constipation by absorbing water into the stool, making it easier to pass. A therapeutic effect of psyllium would be the client experiencing a soft bowel movement, indicating the medication has helped to regulate the client's bowel movements and relieve constipation.

B) Gastric pH 2 (Normal pH: 1-4): While this is a normal gastric pH range, it is not related to the therapeutic effect of psyllium. Psyllium works in the gastrointestinal tract to promote bowel regularity, not to alter gastric pH. The pH measurement of gastric contents is not a relevant indicator of the medication's effectiveness.

C) 500 ml of urine output: This finding is not related to the therapeutic effect of psyllium. Psyllium is intended to address bowel function, not urine output. Adequate urine output should be monitored, but it is not the expected outcome for a patient taking psyllium.

D) Blood glucose: 95 (Normal Fasting Blood Glucose: 60-120): While a normal blood glucose level is important, it is not relevant to the action of psyllium. Psyllium does not have a direct effect on blood glucose levels, so a normal blood glucose result is not indicative of a therapeutic effect of the medication.

A. True B. False

Correct Answer is A

Explanation

CYP 450 enzymes are responsible for the metabolism of many drugs. Smoking can induce certain CYP 450 enzymes, particularly CYP1A2, which leads to an increase in the metabolism of drugs that are substrates of this enzyme. When a person begins smoking, the induction of these enzymes can cause drugs to be metabolized more quickly, which typically results in lower drug levels in the body. However, the statement asks whether the level of medication will increase in this client, and since smoking induces enzyme activity, it would typically lead to decreased, not increased, drug levels. However, in the context of drug-drug interactions and other metabolic pathways, the metabolism rate could be altered in ways that might increase or affect the therapeutic response.

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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 received psyllium this morning. Which assessment finding indicates a therapeutic effect of the medication?

Correct Answer is A

Explanation

A client currently prescribed a medication highly metabolized by the CYP 450 recently began smoking due to a stressful life event. True or False: The level of medication will increase in this client.

Correct Answer is A

Explanation

A client who weighs 45kg is ordered to receive 500 mg of amoxicillin every eight hours. The dosing range noted in the Davis Drug Guide is 20 to 40 mg/kg/day divided and to be given every 8 hours. True or False: the client's dose is safe and therapeutic?

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What factor has the most impact on the pharmacokinetic phase of distribution?

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