an overweight client taking warfarin coumadin has dry skin due to decreased arterial blood flow what should the nurse instruct the client to do select
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Test Bank

1. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

Correct answer: A

Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.

2. A client expresses difficulty voiding in public places. How should the nurse respond?

Correct answer: D

Rationale: The nurse should prioritize the client's privacy when addressing issues related to voiding discomfort in public places. Closing the curtain in the current room would offer immediate privacy and support the client's needs. Turning on the faucet is not an evidence-based intervention for voiding difficulties. Prescribing a diuretic is not appropriate without further assessment. While moving to a room with a private bathroom might be ideal, it may not be immediately feasible, making ensuring privacy in the current setting the most appropriate action.

3. In a patient with cirrhosis, which of the following lab results is most concerning?

Correct answer: D

Rationale: In a patient with cirrhosis, a low platelet count is the most concerning lab result. Thrombocytopenia, or low platelet count, is common in cirrhosis due to impaired platelet production in the liver. It significantly increases the risk of bleeding and can lead to serious complications such as hemorrhage. Elevated liver enzymes (Choice A) are expected in cirrhosis but may not directly indicate the severity of the disease. Low albumin levels (Choice B) are common in cirrhosis and can contribute to fluid retention but do not pose an immediate risk of bleeding. Elevated bilirubin levels (Choice C) are also expected in cirrhosis and typically indicate impaired liver function but do not directly increase the risk of bleeding as much as a low platelet count.

4. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?

Correct answer: B

Rationale: Hypokalemia, defined as a serum potassium level below the normal range of 3.5 to 5 mEq/L, can lead to changes in myocardial irritability and ECG waveform, potentially causing life-threatening dysrhythmias. Therefore, the priority action for the nurse is to initiate continuous cardiac monitoring to promptly detect any abnormal heart rhythms or ventricular ectopy. This monitoring is crucial for assessing the impact of potassium replacement therapy on the cardiac rhythm and ensuring the safety of the client. While administering potassium chloride is important for correcting the hypokalemia, it should occur after cardiac monitoring is in place. Consulting with a dietitian and educating about diuretic side effects are relevant aspects of care but are not the immediate priority in this situation where cardiac monitoring takes precedence for timely intervention.

5. The patient will take a high dose of azithromycin after discharge from the hospital. Which statement by the patient indicates understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Azithromycin peak levels may be reduced by antacids when taken at the same time, so patients should be cautioned to take antacids 2 hours before or 2 hours after taking the drug. Choice B is incorrect because high-dose azithromycin carries a risk for hepatotoxicity when taken with other potentially hepatotoxic drugs such as acetaminophen. Choice C is incorrect as diarrhea may indicate pseudomembranous colitis and should be reported, not expected as a common mild side effect. Choice D is incorrect; there is no restriction for dairy products while taking azithromycin.

Similar Questions

After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?
A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
Which of the following is a key symptom of hyperthyroidism?
A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses