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

Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.

Choice B rationale

Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.

Choice C rationale

Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.

Choice D rationale

Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.

However, this symptom does not require immediate intervention but should be evaluated further.

A. 55-year-old woman with coronary artery disease B. 21-year-old college senior who is being treated for Streptococcus C. 23-year-old woman who recently delivered and has mastitis D. 65-year-old man with dehydration .

Correct Answer is D

Explanation

Choice A rationale

55-year-old woman with coronary artery disease. While patients with coronary artery disease often have multiple comorbidities and may be on medications that could interact with Penicillin G, there is no specific increased risk of adverse reactions to Penicillin G in this population.

Choice B rationale

21-year-old college senior who is being treated for Streptococcus. Penicillin G is often used to treat Streptococcus infections. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.

Choice C rationale

23-year-old woman who recently delivered and has mastitis. Penicillin G can be used to treat mastitis, an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.

Choice D rationale

65-year-old man with dehydration. Dehydration can affect kidney function, and Penicillin G is excreted by the kidneys. Therefore, patients with dehydration or any other condition that reduces kidney function are at a higher risk of adverse reactions to Penicillin G3.

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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 is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Which client does the nurse recognize to have the greatest risk of an adverse reaction if prescribed potassium Penicillin G?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

A patient has been receiving warfarin sodium 2.5 mg PO daily for four days and the International Normalized Ratio (INR) is 1.9. What should be the nurse’s next step?

A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician’s order should the nurse implement?

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

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

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?