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 C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

A. Inject the insulin syringe at a 90-degree angle. B. Avoid the deltoid when injecting the insulin. C. Rotate injection sites correctly. D. Massage the injection site.

Correct Answer is C

Explanation

Choice A rationale

Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.

Choice B rationale

Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.

Choice C rationale

Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.

Choice D rationale

Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.

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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

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Naxlex Comprehensive Predictor Exams

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is providing teaching to a client who is being discharged with a prescription for warfarin. Which information should be included in the teaching for this medication?

The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

A client asks a nurse, “What is a hemoglobin A1C test?” Which of the following is the most appropriate response?

A client undergoing screening for diabetes has a fasting plasma glucose level of 118 mg/dL. What should the nurse plan to educate the client about?

A nurse is caring for a patient who has peripheral arterial disease (PAD). What symptoms should the nurse expect to find in the early stage of the disease?

The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes. What should be the nurse’s teaching priority?

A patient is prescribed metronidazole orally. What statement should be included in the discharge teaching?

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?