Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will use an electric razor when shaving."
Correct. The client should use an electric razor when shaving to reduce the risk of bleeding from minor cuts or nicks. Warfarin is an anticoagulant that inhibits blood clotting and increases the bleeding time.
B. "I will eat more green leafy vegetables to prevent bleeding."
Incorrect. The client should not eat more green leafy vegetables to prevent bleeding. Green leafy vegetables are high in vitamin K, which antagonizes the effect of warfarin and reduces its anticoagulant activity.
C. "I will take an extra dose if I miss one."
Incorrect. The client should not take an extra dose if they miss one. Taking an extra dose can cause excessive anticoagulation and increase the risk of bleeding or hemorrhage.
D. "I will check my blood pressure every day."
Incorrect. The client should not check their blood pressure every day unless instructed by their health care provider. Checking blood pressure every day is not related to warfarin therapy and may cause unnecessary anxiety or confusion.
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Full Explanation
A) Correct. The client should use an electric razor when shaving to reduce the risk of bleeding from minor cuts or nicks. Warfarin is an anticoagulant that inhibits blood clotting and increases the bleeding time.
B) Incorrect. The client should not eat more green leafy vegetables to prevent bleeding. Green leafy vegetables are high in vitamin K, which antagonizes the effect of warfarin and reduces its anticoagulant activity.
C) Incorrect. The client should not take an extra dose if they miss one. Taking an extra dose can cause excessive anticoagulation and increase the risk of bleeding or hemorrhage.
D) Incorrect. The client should not check their blood pressure every day unless instructed by their health care provider. Checking blood pressure every day is not related to warfarin therapy and may cause unnecessary anxiety or confusion.
Similar Questions
A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)
A. Discontinue the IV line and start a new one in another site.
Correct. The nurse should discontinue the IV line and start a new one in another site. The IV site is showing signs of phlebitis, which is inflammation of the vein caused by mechanical, chemical, or bacterial irritation. Phlebitis can lead to complications such as thrombophlebitis, infection, or extravasation.
B. Apply a warm compress to the IV site.
Correct. The nurse should apply a warm compress to the IV site to promote vasodilation and blood flow, which can help reduce inflammation and pain.
C. Elevate the affected extremity on a pillow.
Correct. The nurse should elevate the affected extremity on a pillow to facilitate venous return and decrease edema.
D. Administer an antihistamine to the client.
Incorrect. The nurse should not administer an antihistamine to the client unless prescribed by the health care provider. Antihistamines are used to treat allergic reactions, not phlebitis.
E. Flush the IV line with normal saline.
Incorrect. The nurse should not flush the IV line with normal saline. Flushing the IV line can worsen the inflammation and increase the risk of infection or thrombus formation.
Full Explanation
A) Correct. The nurse should discontinue the IV line and start a new one in another site. The IV site is showing signs of phlebitis, which is inflammation of the vein caused by mechanical, chemical, or bacterial irritation. Phlebitis can lead to complications such as thrombophlebitis, infection, or extravasation.
B) Correct. The nurse should apply a warm compress to the IV site to promote vasodilation and blood flow, which can help reduce inflammation and pain.
C) Correct. The nurse should elevate the affected extremity on a pillow to facilitate venous return and decrease edema.
D) Incorrect. The nurse should not administer an antihistamine to the client unless prescribed by the health care provider. Antihistamines are used to treat allergic reactions, not phlebitis.
E) Incorrect. The nurse should not flush the IV line with normal saline. Flushing the IV line can worsen the inflammation and increase the risk of infection or thrombus formation.
A nurse is teaching a client who has diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include in the teaching?
A. "Store unopened insulin vials in the freezer."
Incorrect. The nurse should instruct the client to store unopened insulin vials in the refrigerator, not in the freezer. Freezing can damage the insulin and make it ineffective.
B. "Rotate injection sites within the same anatomical region."
Correct. The nurse should instruct the client to rotate injection sites within the same anatomical region, such as the abdomen, thighs, arms, or buttocks. Rotating injection sites can prevent lipodystrophy, which is a disorder of fat metabolism that causes hypertrophy or atrophy of subcutaneous tissue.
C. "Mix short-acting and long-acting insulins in the same syringe."
Incorrect. The nurse should instruct the client not to mix short-acting and long-acting insulins in the same syringe. Mixing different types of insulins can alter their onset, peak, and duration of action and affect blood glucose control.
D. "Draw up regular insulin before NPH insulin when mixing them."
Correct. The nurse should instruct the client to draw up regular insulin before NPH insulin when mixing them in the same syringe. This can prevent contamination of the regular insulin vial with NPH insulin, which can affect its potency and clarity.
Full Explanation
A) Incorrect. The nurse should instruct the client to store unopened insulin vials in the refrigerator, not in the freezer. Freezing can damage the insulin and make it ineffective.
B) Correct. The nurse should instruct the client to rotate injection sites within the same anatomical region, such as the abdomen, thighs, arms, or buttocks. Rotating injection sites can prevent lipodystrophy, which is a disorder of fat metabolism that causes hypertrophy or atrophy of subcutaneous tissue.
C) Incorrect. The nurse should instruct the client not to mix short-acting and long-acting insulins in the same syringe. Mixing different types of insulins can alter their onset, peak, and duration of action and affect blood glucose control.
D) Correct. The nurse should instruct the client to draw up regular insulin before NPH insulin when mixing them in the same syringe. This can prevent contamination of the regular insulin vial with NPH insulin, which can affect its potency and clarity.
A nurse is evaluating a client's understanding of their new prescription for albuterol inhaler. Which of the following actions by the client demonstrates correct use of the inhaler?
A. The client shakes the inhaler well before use.
Correct. The client should shake the inhaler well before use to mix the medication and propellant evenly and ensure proper dosage delivery.
B. The client holds their breath for 5 seconds after inhaling.
Incorrect. The client should hold their breath for 10 seconds after inhaling to allow the medication to reach the lower airways and improve bronchodilation.
C. The client exhales fully before placing the mouthpiece in their mouth.
Incorrect. The client should exhale fully after placing the mouthpiece in their mouth and closing their lips around it. This can prevent wasting of medication and ensure optimal inhalation.
D. The client repeats the puff after 15 seconds if needed.
Incorrect. The client should repeat the puff after 1 minute if needed or prescribed. Waiting for 1 minute between puffs can allow enough time for the first puff to take effect and reduce adverse effects such as tachycardia or tremors.
Full Explanation
A) Correct. The client should shake the inhaler well before use to mix the medication and propellant evenly and ensure proper dosage delivery.
B) Incorrect. The client should hold their breath for 10 seconds after inhaling to allow the medication to reach the lower airways and improve bronchodilation.
C) Incorrect. The client should exhale fully after placing the mouthpiece in their mouth and closing their lips around it. This can prevent wasting of medication and ensure optimal inhalation.
D) Incorrect. The client should repeat the puff after 1 minute if needed or prescribed. Waiting for 1 minute between puffs can allow enough time for the first puff to take effect and reduce adverse effects such as tachycardia or tremors.