a nurse is providing discharge teaching to a client who has a new prescription for warfarin which of the following client statements indicates an unde

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

A. I will need to have my INR checked regularly while taking this medication.
B. I should avoid eating leafy green vegetables while taking this medication.
C. I will stop taking this medication if I experience nausea.
D. I will avoid taking aspirin while taking this medication.

Correct answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

2. A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?

A. Sodium 140 mEq/L
B. Potassium 3.8 mEq/L
C. Blood glucose 90 mg/dL
D. Urine ketones present

Correct answer: D

Rationale: The correct answer is D: Urine ketones present. The presence of urine ketones indicates dehydration and inadequate glucose control in clients with hyperemesis gravidarum. Reporting this finding to the provider is crucial for prompt intervention to prevent further complications. Choices A, B, and C are within normal ranges and do not directly correlate with the condition of hyperemesis gravidarum. Therefore, they are not the priority values to report in this scenario.

3. How should pain be assessed in a non-verbal patient?

A. Observe facial expressions
B. Use the Wong-Baker faces scale
C. Assess heart rate
D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

4. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

A. Do you understand the voices are not real?
B. Why do you think the voices are talking to you?
C. Have you tried going to a quiet place when this occurs?
D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

5. How should signs of dehydration in an elderly patient be assessed?

A. Monitor skin turgor
B. Check for dry mucous membranes
C. Monitor for sunken eyes
D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.