a nurse is providing discharge teaching for a client prescribed warfarin what should be included in the teaching
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?

Correct answer: D

Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.

2. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?

Correct answer: D

Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.

3. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?

Correct answer: B

Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.

4. Which of the following is a common manifestation of opioid withdrawal?

Correct answer: B

Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.

5. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Correct answer: D

Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.

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