Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Hold the warfarin until the next day’s dose and notify the laboratory.
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.
B. Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted.
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.
C. Administer the daily dose of warfarin as these are the expected side effects of the medication.
Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.
D. Hold the warfarin until the healthcare provider is notified of the assessment findings.
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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Full Explanation
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.
Similar Questions
A newly admitted client has been prescribed trimethoprim-sulfamethoxazole.
The nurse understands that this medication is contraindicated based on which lab result?
A. Serum fasting glucose of 101 mg/dL.
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
B. Platelets of 160,000 uL.
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
C. Hemoglobin of 13.6 g/dL.
]A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
D. Serum creatinine of 2.5 mg/dL.
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.
Full Explanation
Choice A rationale
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice B rationale
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice C rationale
A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice D rationale
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.
The nurse is providing teaching to a client who is being discharged with a prescription for warfarin. Which information should be included in the teaching for this medication?
A. Omit green, leafy vegetables from the diet.
While it is true that warfarin’s effectiveness can be affected by vitamin K, found in green leafy vegetables, it is not necessary to completely omit these from the diet. Instead, maintaining a consistent intake of vitamin K can help keep INR levels stable.
B. Use over-the-counter pain relief medications.
Over-the-counter pain relief medications, especially those that are nonsteroidal anti- inflammatory drugs (NSAIDs), can increase the risk of bleeding when taken with warfarin. Therefore, this advice is not correct.
C. Obtain laboratory tests as directed.
Regular laboratory tests, specifically the International Normalized Ratio (INR), are crucial when taking warfarin to monitor its effectiveness and adjust the dosage if necessary.
D. Use an electric razor for shaving.
Using an electric razor can help prevent cuts and bleeding, which is important because warfarin is a blood thinner. However, this information is not as critical as obtaining regular laboratory tests.
E. Obtain a medical alert bracelet.
Full Explanation
Choice A rationale
While it is true that warfarin’s effectiveness can be affected by vitamin K, found in green leafy vegetables, it is not necessary to completely omit these from the diet. Instead, maintaining a consistent intake of vitamin K can help keep INR levels stable.
Choice B rationale
Over-the-counter pain relief medications, especially those that are nonsteroidal anti- inflammatory drugs (NSAIDs), can increase the risk of bleeding when taken with warfarin. Therefore, this advice is not correct.
Choice C rationale
Regular laboratory tests, specifically the International Normalized Ratio (INR), are crucial when taking warfarin to monitor its effectiveness and adjust the dosage if necessary.
Choice D rationale
Using an electric razor can help prevent cuts and bleeding, which is important because warfarin is a blood thinner. However, this information is not as critical as obtaining regular laboratory tests.
Choice E rationale
Obtaining a medical alert bracelet can be beneficial for individuals taking warfarin, as it can alert healthcare professionals in an emergency situation about the individual’s use of a blood thinner. However, this information is not as critical as obtaining regular laboratory tests.
A Type 1 diabetic client with a morning (fasting) glucose of 260 mg/dL has been diagnosed with the Somogyi effect from insulin administration.
What intervention should the nurse anticipate including in the plan of care?
A. Increase the nighttime insulin glargine dose.
Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.
B. Ensure a snack is consumed at bedtime.
Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.
C. Check the morning cortisol level.
Checking the morning cortisol level is not directly related to managing the Somogyi effect.
D. Check the glucose level at 2 a.m. and 8 a.m.
Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.
Full Explanation
Choice A rationale
Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.
Choice B rationale
Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.
Choice C rationale
Checking the morning cortisol level is not directly related to managing the Somogyi effect.
Choice D rationale
Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.