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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

Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

Correct Answer: C

Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.

Question 3 of 5

A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

Correct Answer: D

Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Question 4 of 5

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?

Correct Answer: C

Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.

Question 5 of 5

The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.

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