As home health nurse, you are taking an admission history for a client who has a deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?

Correct Answer: A

Rationale: The correct answer is option A) "I have started to eat more healthy foods like green salads and fruit." This statement indicates a potential lack of understanding about warfarin therapy because consuming large amounts of green, leafy vegetables rich in vitamin K can interfere with the effectiveness of warfarin. Vitamin K is essential for normal blood clotting, and warfarin works by inhibiting vitamin K-dependent clotting factors. Therefore, a sudden increase in vitamin K intake can reduce the anticoagulant effects of warfarin. Option B) "The doctor said that it is important to avoid becoming constipated" is incorrect because constipation, while it can affect medication absorption in some cases, is not directly related to warfarin therapy. Option C) "Coumadin makes me feel a little nauseated unless I take it with food" is incorrect because taking warfarin with food to reduce nausea is a common practice and does not necessarily indicate a need for additional teaching. Option D) "I will need to have some blood testing done once or twice a week" is incorrect because regular blood testing to monitor the International Normalized Ratio (INR) levels is a standard part of warfarin therapy and does not indicate a lack of understanding. In an educational context, it is crucial to emphasize to patients on warfarin therapy the importance of maintaining a consistent intake of vitamin K-rich foods to ensure the medication's effectiveness. This case highlights the need for clear and detailed patient education regarding dietary considerations when taking warfarin to prevent complications and ensure optimal therapeutic outcomes.

Correct Answer: B

Rationale: In the context of a long-term-care client with chronic lymphocytic leukemia experiencing activity intolerance due to weakness and anemia, delegating the task of checking the client's blood pressure and pulse rate after ambulation to a nursing assistant is the most appropriate choice. This task is within the scope of practice for a nursing assistant and directly relates to monitoring the client's physiological response to activity, which is crucial in assessing their tolerance levels and adjusting care plans accordingly. Option A, evaluating the client's response to normal activities of daily living, requires a higher level of clinical judgment and interpretation of findings, making it more suitable for a licensed nurse. Option C, determining self-care activities the client can do independently, involves assessing the client's functional abilities and should be done by a healthcare provider with a comprehensive understanding of the client's condition and limitations. Option D, assisting the client in choosing a diet to improve strength, involves nutritional assessment and individualized planning, which falls under the scope of a registered dietitian or a nurse with specific training in nutrition. Educationally, understanding the principles of delegation based on scope of practice and client needs is essential for effective healthcare team collaboration. By correctly delegating tasks, nurses can optimize efficiency, promote patient safety, and ensure quality care delivery tailored to each client's unique requirements. Nurses must possess a solid grasp of delegation principles to allocate responsibilities appropriately and maximize the effectiveness of the healthcare team.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) A 36-year-old client with chronic renal failure who will need a subcutaneous injection of epoetin (Procrit). The LPN/LVN is most likely to be assigned to provide care and administer medications to this client because administering subcutaneous injections falls within the scope of practice for LPNs/LVNs. Administering epoetin requires knowledge of safe injection techniques, monitoring for adverse reactions, and understanding the medication's purpose in treating anemia associated with chronic renal failure. Option B) is incorrect because administering a blood transfusion requires a higher level of training and assessment skills that are typically within the RN's scope of practice. Option C) is incorrect because phlebotomy for a client with polycythemia vera involves specialized knowledge and monitoring of blood parameters, which is more aligned with the RN's role. Option D) is incorrect because a bone marrow aspiration is a more complex procedure requiring specialized training and assessment skills, typically performed by a physician or under direct supervision of a healthcare provider with advanced training. In an educational context, it is crucial for nursing students to understand the scope of practice for different levels of nursing personnel to ensure safe and effective patient care assignments. Understanding these roles and responsibilities helps in providing quality care while promoting interprofessional collaboration within the healthcare team.

Correct Answer: B

Rationale: In this scenario, the most immediate concern for the nurse is option B) The client has an oral temperature of 99.7°F. Explanation: 1. Correct Answer: A post-splenectomy patient is at risk for infection due to the spleen's role in filtering bacteria from the blood. A temperature of 99.7°F could indicate the presence of an infection, which is a serious concern considering the client's recent splenectomy. 2. Incorrect Options: A) Engaging in unprotected sex may raise concerns about sexually transmitted infections, but in this context, infection risk post-splenectomy is more critical. C) Abdominal pain with light palpation could be due to various reasons, but infection needs immediate attention. D) Occasional marijuana use, while important for overall health, is not the most immediate concern in this case. Educational Context: Understanding the increased risk of infection post-splenectomy is crucial for nurses in hematology/oncology. Assessing vital signs and promptly identifying signs of infection are essential to prevent serious complications in these patients. This question highlights the importance of prioritizing assessment findings based on the patient's unique health status.

Correct Answer: C

Rationale: In this scenario, assigning the LPN with 2 years of experience on the oncology unit to care for the client with a low ANC is the most appropriate choice. The LPN's familiarity with oncology unit protocols, procedures, and patient population makes them well-suited for this assignment. Their experience indicates they have likely received specific training in managing oncology patients, including those in protective isolation. Option A, the LPN from the same-day-surgery unit, lacks the specialized experience required for oncology care. Option B, the RN from the float pool with a background in surgical care, may not have the expertise needed for oncology patients. Option D, the RN from the ED, may also lack the specialized knowledge and skills necessary for caring for oncology patients in protective isolation. In an educational context, this question highlights the importance of matching staff expertise with the specific needs of patients in different care settings. It underscores the significance of experience and training in specialized areas like oncology, where patients often require complex care and interventions. By understanding the rationale behind staffing assignments, healthcare professionals can ensure the best possible outcomes for their patients.