Which instruction should the nurse provide an unlicensed assistive personnel (UAP) who is assisting with the personal care of a client receiving clopidogrel?

Maintain a cool, calm room environment.

Provide the client with a soft toothbrush.

Allow the client ample rest periods.

Keep the head of the bed elevated.

Answer and Explanation

The Correct Answer is B

A) Maintain a cool, calm room environment: While a calm environment can be beneficial for overall patient well-being, it is not specifically related to the care of a client on clopidogrel. This instruction does not address the direct needs or precautions associated with clopidogrel use.
B) Provide the client with a soft toothbrush: Clopidogrel is an antiplatelet medication that increases the risk of bleeding. To minimize gum bleeding and oral mucosal damage, it is crucial to use a soft toothbrush to prevent injury. This measure helps to reduce the risk of bleeding complications associated with the medication.
C) Allow the client ample rest periods: While rest is important for overall health, it is not specifically related to the precautions needed for a client on clopidogrel. The primary concern with clopidogrel is managing bleeding risks rather than providing rest.
D) Keep the head of the bed elevated: Elevating the head of the bed is generally useful for managing certain conditions like respiratory issues or gastrointestinal reflux but does not directly relate to the specific needs of a client taking clopidogrel. The focus for clients on clopidogrel should be on preventing bleeding complications.

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Correct Answer is C

Explanation

A) Administer the scheduled dose: Administering the scheduled dose of warfarin when the INR is 5.0 is not appropriate because this INR level is significantly elevated, indicating a high risk of bleeding. Warfarin dosing should be adjusted based on INR levels to prevent complications such as excessive bleeding.
B) Discontinue the warfarin schedule: Completely discontinuing warfarin may not be necessary unless there are additional factors or signs of bleeding. It is essential to take appropriate action based on the INR level, but discontinuation should be guided by further evaluation and healthcare provider recommendations.
C) Withhold warfarin for 24 hours: Withholding the dose of warfarin is the correct action when faced with an elevated INR of 5.0. This intervention is crucial to prevent potential bleeding complications while waiting for further evaluation and guidance from the healthcare provider regarding additional management, such as administration of vitamin K or other reversal agents.

D) Obtain another INR analysis immediately: While obtaining another INR analysis can be helpful in monitoring trends, it is not the immediate priority if the INR is already 5.0. The primary action should be to withhold the dose and consult with the healthcare provider to determine the appropriate next steps for managing the elevated INR and ensuring patient safety.

A. 40-year-old female with frequent vaginal infections. B. A 50-year-old male with a history of angina. C. An 18-year-old pregnant female with type 1 diabetes mellitus. D. A 75-year-old male with bone cancer.

Correct Answer is B

Explanation

Simvastatin is a medication used to lower cholesterol and reduce the risk of cardiovascular events, such as heart attacks. It is most commonly prescribed to individuals with a history of heart disease, high cholesterol, or related conditions like angina. The other options are less likely to benefit from simvastatin based on the information provided.

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Which instruction should the nurse provide an unlicensed assistive personnel (UAP) who is assisting with the personal care of a client receiving clopidogrel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement? Reference Range: International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

Correct Answer is C

Explanation

The nurse is preparing client teaching materials on commonly used medications. Which client is most likely to benefit from a client education packet about simvastatin?

Correct Answer is B

Explanation

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Which instruction should the nurse provide an unlicensed assistive personnel (UAP) who is assisting with the personal care of a client receiving clopidogrel?