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Questions 164

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Question 1 of 5

The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.

Correct Answer: C,D,E

Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.

Question 2 of 5

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Correct Answer: C

Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

Question 3 of 5

The nurse is talking with the parent of a 14-month-old client who was exposed to measles 2 days ago. The client has not received the measles, mumps, and rubella (MMR) vaccine. Which of the following statements would be most appropriate for the nurse to make?

Correct Answer: A

Rationale: Post-exposure MMR vaccination within 72 hours can prevent measles in unvaccinated individuals. Monitoring temperature or assuming no symptoms means no infection is incorrect, as measles has an incubation period. Measles spreads via respiratory droplets, not just rash contact.

Question 4 of 5

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply.

Correct Answer: A,C,E

Rationale: Inspecting the home identifies lead sources (e.g., paint, dust). Frequent hand washing reduces ingestion of lead dust. Follow-up testing monitors levels. Vacuuming may spread lead dust; wet mopping is preferred. Hot water can leach lead from pipes; cold water is safer.

Question 5 of 5

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

Correct Answer: B

Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

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