The nurse is reinforcing teaching for a patient who has had a mechanical valve replacement. What should be included regarding safety during warfarin (Coumadin) therapy?
a. Wear Medic-Alert identification.
b. Use a straight razor when shaving.
c. Keep yearly blood test appointments.
d. Increase intake of green leafy vegetables.
ANS: A
If the patient is on anticoagulants for mechanical valve replacement, medical identification should be used. D. A steady (rather than fluctuating) amount of green leafy vegetables should be eaten so that international normalized ratio (INR) values do not fluctuate due to the vitamin K found in these foods. C. Monthly blood tests are done. B. Avoid a straight razor to avoid cuts and bleeding.
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A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.
A nurse manager has provided education to emergency department nurses regarding disaster management. Which statement would the manager interpret as indicating understanding of this education?
1. "We should treat as many clients as possible as quickly as possible." 2. "Quick separation of any victim with bleeding wounds from those who are not bleeding is essential." 3. "Our goal is to treat those with serious injuries first." 4. "We should send those with less serious injuries home without treatment."
A 68-year-old male patient has chronic obstructive pulmonary disease (COPD). He has a markedly increased need for protein and calories to maintain an adequate nutritional status
To help him get the nutrition he needs, the nurse would encourage him to a. eat three meals a day. b. rest 30 minutes before eating. c. drink fluids only with meals. d. perform bronchial drainage 30 minutes after eating.
A client is sensitive to light. Which intervention would the nurse teach the client as appropriate for this problem?
A) dim the lights on sunny days B) remove lampshades to provide more light C) place dark patterned rugs on stairs D) use supplementary lamps near work