A client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily and has started taking Ginkgo biloba. What is the priority action for the nurse to take?
a. Encourage the use of Ginkgo biloba to enhance the client's systemic circulation.
b. Assess the client for any bruising or pete-chiae.
c. Explain that replacing Ginkgo biloba with garlic would be much safer.
d. Assess for any forgetfulness or inappro-priate speech.
B
Taking Ginkgo biloba with warfarin increases the client's risk of bleeding. Therefore, the client should be monitored first for bruising or bleeding associated with use of this combination. Gink-go biloba is purported to reduce memory problems and dementia and has vasodilator properties, but these uses cannot be supported if the client is on an anticoagulant for the heart valve re-placement. Garlic would not be a safer choice because it can act as an antiplatelet agent and would increase the risk of bleeding with warfarin (Coumadin).
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The patient with heat stroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2° F. When the patient starts to shiver, the emergency department nurse should:
a. raise the head of the bed. b. offer warm liquids. c. remove cold packs and fan. d. continue with cooling interventions.
The daughter of an older adult patient who has just returned from surgery is distressed about her father's pale, cold hands and feet. The nurse covers the patient with an extra blanket and responds:
1. "Don't be concerned. It is quite cold in the operating room. Your dad will be warm in a minute." 2. "Older patients like your dad get a little ‘shocky' during surgery." 3. "When patients have blood loss during surgery, superficial vessels close off tem-porarily, making for cold extremities." 4. "We are watching the disturbed circulation in your dad's hands and feet very carefully."
Changing a person's center of attention is:
a. Guided imagery b. Distraction c. Circadian rhythm d. Relaxation
The ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?
1. Instruct the client to limit protein intake. 2. Teach the client to avoid adding salt to foods. 3. Discuss the rationale for reducing or maintaining weight. 4. Stress the importance of a regular exercise program.