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 A

Explanation

Choice A rationale

The hemoglobin A1C test, also known as the HbA1C or glycated hemoglobin test, is a blood test that evaluates glycemic control over a 3-month period by measuring the glucose attached to hemoglobin. This test is commonly used to diagnose and monitor diabetes. It provides an average of your blood sugar levels over the past 2-3 months, which can help healthcare providers assess how well diabetes is being managed.

Choice B rationale

The hemoglobin A1C test does not use the level of serum protein to evaluate glycemic control. Instead, it measures the amount of glucose that is attached to the hemoglobin in your red blood cells.

Choice C rationale

The hemoglobin A1C test does not evaluate serum ketone production over several days. Ketones are produced when the body burns fat for energy, which can occur when there is not enough insulin to help your body use sugar for energy. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.

Choice D rationale

The hemoglobin A1C test does not determine the amount of glucose attached to hemoglobin over the last seven days. Instead, it provides an average of your blood sugar levels over the past 2-3 months. -

A. Omitted meals B. Polydipsia and polyphagia C. Not taking enough insulin D. An insulin overdose

Correct Answer is C

Explanation

Choice A rationale

Omitted meals can lead to hypoglycemia, not diabetic ketoacidosis (DKA). DKA is caused by a lack of insulin, not a lack of food intake.

Choice B rationale

Polydipsia and polyphagia are symptoms of hyperglycemia, not causes of DKA. They occur as the body tries to compensate for high blood sugar levels.

Choice C rationale

Not taking enough insulin is a primary cause of the development of DKA. Without enough insulin, the body begins to break down fat for fuel, which produces acids known as ketones.

Choice D rationale

An insulin overdose would lead to hypoglycemia, not DKA. DKA is caused by a lack of insulin, not an excess.

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

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is teaching an adult patient with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is aware that the diagnostic level of a fasting blood glucose for a client with diabetes is:

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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?