a nurse is providing discharge teaching for a client prescribed warfarin what should be included in the teaching
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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. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?

Correct answer: A

Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.

3. How should a healthcare professional position a patient to reduce the risk of pressure ulcers?

Correct answer: B

Rationale: Correctly positioning a patient to reduce the risk of pressure ulcers involves using pillows to support bony prominences. This helps to relieve pressure from vulnerable areas and prevent the development of pressure ulcers. Choice A is incorrect because keeping a patient in the supine position for extended periods can increase the risk of pressure ulcers. Choice C is incorrect as turning the patient every 2 hours, rather than every 4 hours, is recommended to prevent pressure ulcers. Choice D is not the best option mentioned for positioning a patient to reduce pressure ulcer risk; although alternating pressure mattresses can be beneficial, using pillows for support is a more direct and commonly used method.

4. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

Correct answer: B

Rationale: The correct answer is B: Teaching the patient to select nutritious foods. A nutritious diet plays a crucial role in strengthening the body's immune system, making it more capable of fighting off infections. Vitamins, minerals, and other nutrients found in healthy foods support immune function and overall health. Teaching the patient about taking a temperature (choice A) may be important for monitoring for signs of infection but does not directly decrease the risk of infection. Teaching about the effects of alcohol (choice C) and fall prevention (choice D) are important aspects of patient education but are not directly related to decreasing the risk of infection in a susceptible patient.

5. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.

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