Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?
A. Increase the intake of dark green leafy vegetables while taking warfarin.
Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.
B. Eat two servings of dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.
Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.
C. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
This is the correct answer because eating approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent is a good instruction because it can help maintain a stable therapeutic level of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Keeping a consistent intake of vitamin K can help avoid fluctuations in warfarin's effect and prevent bleeding or clotting episodes.
D. Avoid eating any foods that contain any vitamin K because it is an antagonist of warfarin.
Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.
This question is an excerpt from Nurse Dive's nursing test bank - HESI Exit II Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.
Choice B reason: Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.
Choice D reason: Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.
Similar Questions
A nurse is performing an admission assessment for a male client scheduled for the removal of an internal fixation device from a previous ankle fracture. The client informs the nurse that he was recently treated with intravenous vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which of the following actions should the nurse take? (Select all that apply.)
A. Continue to monitor the client for signs of an infection.
Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.
B. Call the healthcare provider for a prescription for linezolid.
Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.
C. Collect multiple sets of blood cultures for MRSA screening.
Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.
D. Place the client on contact transmission precautions.
Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.
E. Obtaining a sputum specimen for culture and sensitivity
This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.
Full Explanation
Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.
Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.
Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.
Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.
Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?
A. Explain to the client that the dosage has been changed.
Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether or not he takes it.
Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
D. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
Full Explanation
Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
A. Ineffective coping related to denial
Choice A reason: This is the correct answer because ineffective coping related to denial is a likely problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Denial is a defense mechanism that helps people avoid facing unpleasant or threatening realities, such as having a heart attack and needing hospitalization and treatment. The nurse should assess the client's coping skills and provide emotional support and education.
B. Emotional conflict due to stress
Emotional conflict due to stress is not a specific problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Emotional conflict is a state of having mixed or contradictory feelings about something or someone, such as family, work, or self. Stress is a response to any physical, psychological, or environmental demand that exceeds one's coping resources. The nurse should assess the client's sources of stress and conflict and help him manage them.
C. Deficient knowledge of MI lifestyle changes
Deficient knowledge of MI lifestyle changes is not a primary problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Deficient knowledge is a state of lacking information or understanding about something, such as disease process, treatment options, or self-care measures. Lifestyle changes are modifications in one's habits or behaviors that promote health and well-being, such as diet, exercise, smoking cessation, or stress management. The nurse should assess the client's learning needs and readiness and provide appropriate education.
D. Anxiety related to treatment plan
Anxiety related to treatment plan is not an evident problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Anxiety is a feeling of apprehension, worry, or fear that interferes with one's normal functioning or well-being. Treatment plan is a set of goals, interventions, and outcomes that guide the care of a client with a specific health problem, such as MI. The nurse should assess the client's level of anxiety and provide information and reassurance about his treatment plan.
Full Explanation
Choice B reason: Emotional conflict due to stress is not a specific problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Emotional conflict is a state of having mixed or contradictory feelings about something or someone, such as family, work, or self. Stress is a response to any physical, psychological, or environmental demand that exceeds one's coping resources. The nurse should assess the client's sources of stress and conflict and help him manage them.
Choice C reason: Deficient knowledge of MI lifestyle changes is not a primary problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Deficient knowledge is a state of lacking information or understanding about something, such as disease process, treatment options, or self-care measures. Lifestyle changes are modifications in one's habits or behaviors that promote health and well-being, such as diet, exercise, smoking cessation, or stress management. The nurse should assess the client's learning needs and readiness and provide appropriate education.
Choice D reason: Anxiety related to treatment plan is not an evident problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Anxiety is a feeling of apprehension, worry, or fear that interferes with one's normal functioning or well-being. Treatment plan is a set of goals, interventions, and outcomes that guide the care of a client with a specific health problem, such as MI. The nurse should assess the client's level of anxiety and provide information and reassurance about his treatment plan.
