The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities.

What should be the nurse’s initial action?

Hold the warfarin until the next day’s dose and notify the laboratory.

Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted.

Administer the daily dose of warfarin as these are the expected side effects of the medication.

Hold the warfarin until the healthcare provider is notified of the assessment findings.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.

Choice B rationale

Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.

Choice C rationale

Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.

Choice D rationale

The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.

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Correct Answer is B

Explanation

Choice A rationale

Soaking feet once daily in warm water is not recommended for diabetic patients. This is because prolonged soaking can lead to skin breakdown and increase the risk of foot ulcers and infections.

Choice B rationale

Utilizing a mirror to examine the soles of the feet is a recommended practice for diabetic patients. This allows them to check for any cuts, sores, blisters, or changes in the skin that they may not be able to see otherwise. Early detection of these issues can prevent serious complications such as infections and ulcers.

Choice C rationale

Cutting nails in a curved direction is not advised for diabetic patients. This can lead to ingrown toenails, which can cause sores and infections. It’s recommended to cut the nails straight across to avoid this.

Choice D rationale

Using a commercial medicine to remove a corn is not recommended for diabetic patients. These products can damage the skin and increase the risk of ulcers and infections. Any issues with corns or calluses should be addressed by a healthcare professional.

A. Activated Partial Thromboplastin Time (aPTT) of 25. B. D-dimer of 500 ng/mL. C. Prothrombin Time (PT) of 14 seconds. D. Platelet count of 148,000 uL.

Correct Answer is B

Explanation

Choice A rationale

Activated Partial Thromboplastin Time (aPTT) of 25 is within the normal range (25-35 seconds) and is not directly related to deep vein thrombosis (DVT)89.

Choice B rationale

A D-dimer level of 500 ng/mL is elevated (normal range is typically less than 250 ng/mL), which can indicate the presence of a clot, such as in DVT8910.

Choice C rationale

Prothrombin Time (PT) of 14 seconds is within the normal range (11-13.5 seconds) and is not directly related to DVT89.

Choice D rationale

A platelet count of 148,000 uL is within the normal range (150,000-450,000 uL) and is not directly related to DVT89.

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The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches a diabetic patient how to perform foot care. Which action by the patient would indicate that they can correctly perform foot care?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities.

What should be the nurse’s initial action?