You are writing a care plan for a patient who is taking anticoagulant.
What would be an appropriate nursing diagnosis?
Maintain narcan on standby.
Notify the healthcare provider of any patient receiving this drug.
Evaluate patient for PT for 2.5.
Establish safety precautions.
The Correct Answer is D
Choice A rationale
Maintaining narcan (naloxone) on standby is not directly related to anticoagulant therapy. Narcan is used to reverse opioid overdoses, not to manage the effects of anticoagulants.
Choice B rationale
Notifying the healthcare provider of any patient receiving this drug is a general action but not an appropriate nursing diagnosis. Nursing diagnoses focus on identifying specific patient needs and planning care to address those needs.
Choice C rationale
Evaluating the patient for PT (prothrombin time) for 2.5 is an action, not a nursing diagnosis. Nursing diagnoses identify patient needs and risks, guiding the planning and implementation of care.
Choice D rationale
Establishing safety precautions is an appropriate nursing diagnosis for a patient on anticoagulant therapy. Anticoagulants increase the risk of bleeding, so ensuring patient safety and preventing injury is crucial to minimize this risk. .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering the medication even if the name of the drug can be clearly read is risky because the rest of the label might contain essential information like dosage, expiration date, and other critical instructions. Administering a medication without complete labeling increases the risk of medication errors.
Choice B rationale
Discarding the entire bottle and contents and obtaining a new bottle is the safest option. It ensures that the nurse is using a medication with a fully intact label, which includes all necessary information to safely administer the medication, such as dosage, route, and expiration date.
Choice C rationale
Asking another nurse to verify the contents of the bottle is not sufficient because the torn and soiled label still lacks complete information. Without all details, there's a risk of administering the wrong dosage or an expired medication.
Choice D rationale
Finding the drug information and making a new label for the bottle is not appropriate because it does not guarantee the accuracy of the dosage or other critical details that were on the original label. It's better to use a completely labeled and verified medication bottle.
Correct Answer is A
Explanation
Choice A rationale
Using an “ouch” scale, such as the Wong-Baker FACES Pain Rating Scale, is appropriate for young children. It allows them to express their pain intensity in a way that is understandable and relatable to their age group.
Choice B rationale
Encouraging a six-year-old to request pain medication may not be effective, as they might not understand when they need it or might be reluctant to ask.
Choice C rationale
Waiting to administer pain medication until the child begins to cry can delay pain relief, leading to unnecessary discomfort and anxiety.
Choice D rationale
Asking a young child to rate their pain on a scale of 1 to 10 might be confusing and less effective than using a more child-friendly method like the “ouch” scale.
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