A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?
Increased cholesterol level
Distended jugular vein
Bleeding
Angina
The Correct Answer is C
A. Increased cholesterol levels are not directly related to garlic intake or the effects of warfarin.
B. Distended jugular veins may indicate fluid overload or heart failure but are not a direct concern related to warfarin and garlic interaction.
C. Garlic can enhance the anticoagulant effect of warfarin, increasing the risk of bleeding; therefore, monitoring for signs of bleeding is crucial.
D. Angina is not a direct consequence of the interaction between garlic and warfarin and does not specifically relate to the assessment for this patient.
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Correct Answer is D
Explanation
A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.
Correct Answer is ["A","B","C","D"]
Explanation
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.