,
,
, 4. A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a
need for further teaching?
A. "I have started taking ginger root to treat my joint stiffness."
Rationale: Ginger root can interfere with the blood clotting effect of warfarin and place the client at risk for
bleeding. This statement indicates the client needs further teaching.
B. "I take this medication at the same time each day."
Rationale: The client should take warfarin at the same time each day to maintain a stable blood level.
C. "I eat a green salad every night with dinner."
Rationale: Green leafy vegetables are a good source of vitamin K, which can interfere with the clotting
effects of warfarin. Clients who are taking warfarin do not need to restrict dietary vitamin K intake
but rather should maintain a consistent intake of vitamin K in order to control the therapeutic
effect of the medication.
D. "I had my INR checked three weeks ago."
Rationale: Clients who have been taking warfarin for more than 3 months should have their INR level
checked every 2 to 4 weeks.
5. A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an
influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of
the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?
A. The client's age is 62.
Rationale: Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is
contraindicated for this client. Pregnancy and immunocompromised status are also
contraindications.
B. The client smokes one pack of cigarettes a day
Rationale: Cigarette smoking is not a contraindication for receiving the LIAV.
C. The client has a history of myocardial infarction.
Rationale: A history of myocardial infarction is not a contraindication for receiving the LIAV.
D. The client has recently traveled to Europe.
Rationale: Recent travel to Europe is not a contraindication for receiving the LIAV.
6. A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the
nurse include in the teaching?
,
, 4. A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a
need for further teaching?
A. "I have started taking ginger root to treat my joint stiffness."
Rationale: Ginger root can interfere with the blood clotting effect of warfarin and place the client at risk for
bleeding. This statement indicates the client needs further teaching.
B. "I take this medication at the same time each day."
Rationale: The client should take warfarin at the same time each day to maintain a stable blood level.
C. "I eat a green salad every night with dinner."
Rationale: Green leafy vegetables are a good source of vitamin K, which can interfere with the clotting
effects of warfarin. Clients who are taking warfarin do not need to restrict dietary vitamin K intake
but rather should maintain a consistent intake of vitamin K in order to control the therapeutic
effect of the medication.
D. "I had my INR checked three weeks ago."
Rationale: Clients who have been taking warfarin for more than 3 months should have their INR level
checked every 2 to 4 weeks.
5. A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an
influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of
the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?
A. The client's age is 62.
Rationale: Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is
contraindicated for this client. Pregnancy and immunocompromised status are also
contraindications.
B. The client smokes one pack of cigarettes a day
Rationale: Cigarette smoking is not a contraindication for receiving the LIAV.
C. The client has a history of myocardial infarction.
Rationale: A history of myocardial infarction is not a contraindication for receiving the LIAV.
D. The client has recently traveled to Europe.
Rationale: Recent travel to Europe is not a contraindication for receiving the LIAV.
6. A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the
nurse include in the teaching?
