A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?

Correct Answer: C

Rationale: The correct answer is C: Use a soft-bristled toothbrush. Patients on warfarin are at risk for bleeding due to its anticoagulant effect. Using a soft-bristled toothbrush helps prevent gum bleeding and injury to the gums, reducing the risk of bleeding complications. Avoiding green leafy vegetables (choice A) is not necessary, as consistent intake is key for warfarin dosing. Taking aspirin (choice B) can increase the risk of bleeding. Limiting fluid intake (choice D) is not indicated in this case.

Correct Answer: C

Rationale: The correct answer is C: Presbycusis. This age-related condition refers to gradual hearing loss typically seen in older adults. In this case, the client's complaint of people whispering and mumbling suggests difficulty hearing clearly, which aligns with symptoms of presbycusis. Delirium (choice A) is characterized by acute confusion and disorientation, not specifically related to hearing loss. Presbyopia (choice B) is a condition of aging that affects near vision, not hearing. Cerebral dysfunction (choice D) refers to broader cognitive impairment, not specifically related to hearing loss as in presbycusis. Therefore, choice C is the most likely age-related condition in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Kayexalate retention enema. In acute renal failure with high serum potassium levels, the priority is to lower potassium levels to prevent cardiac complications. Kayexalate works by exchanging sodium ions for potassium ions in the intestines, promoting potassium excretion in the feces. This intervention helps reduce serum potassium levels quickly. A: Nitrofurantoin is an antibiotic used to treat urinary tract infections, unrelated to managing hyperkalemia. B: Erythropoietin is a hormone used to stimulate red blood cell production, not indicated for reducing potassium levels. D: Azathioprine is an immunosuppressant used for various conditions like autoimmune diseases, not for managing hyperkalemia. In summary, the correct intervention is to administer a Kayexalate retention enema to lower serum potassium levels effectively in acute renal failure. Other options are not appropriate for managing hyperkalemia.

Correct Answer: D

Rationale: The correct answer is D: Risk for injury. The client's symptoms of disorientation, wandering, decreased appetite, and difficulty sleeping indicate an increased risk for falls, accidents, or getting lost. Ensuring the client's safety and preventing any potential harm is the priority. A: Disturbed thought processes may contribute to the client's disorientation but do not pose an immediate threat to their safety. B: Altered sleep pattern is concerning but is secondary to the risk of injury in this scenario. C: Imbalanced nutrition: less than is important, but the immediate priority is addressing the client's safety due to the risk of injury. In summary, the priority nursing problem for this client is the risk for injury due to their disorientation and wandering behavior, which could lead to accidents or harm.