the nurse is providing discharge teaching to a client with a new prescription for warfarin coumadin which dietary instruction should the nurse include
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?

Correct answer: A

Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.

2. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

3. The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

Correct answer: B

Rationale: The correct answer is B. Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness. Choices A, C, and D are incorrect because they do not provide the optimal support and security needed for a client with right-sided weakness. Standing on the weak side and holding the gait belt from the back is the most effective way to assist the client while minimizing the risk of falls.

4. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

Correct answer: A

Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.

5. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct answer: C

Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.

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