Author Question: When reviewing a patient's history and physical information, the nurse notes that the patient has ... (Read 57 times)

vinney12 · **on:** Jul 24, 2018

When reviewing a patient's history and physical information, the nurse notes that the patient has physician's orders for chloral hydrate and warfarin.

During assessment of this patient, the nurse observes areas of petechiae and ecchymosis on the upper and lower extremities. The most appropriate lab work for the nurse to assess next is
a. liver function studies.
b. C-reactive protein.
c. sedimentation rate.
d. prothrombin time.

Question 2

The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. At bedtime, which nursing action will assist the patient to sleep?

a. Offering the patient hot tea
b. Encouraging the patient to ambulate in the hallway
c. Performing back massage
d. Administering an analgesic

mfedorka · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

ANS: D
Chloral hydrate may enhance the anticoagulant effects of warfarin. The patient should be observed for petechiae, ecchymoses, nosebleeds, bleeding gums, dark tarry stools, and bright red or coffee-ground emesis. Prothrombin time should be monitored, and the physician should reduce the dosage of warfarin, if necessary.

Answer to Question 2

ANS: C
Providing a back rub will promote relaxation and reduce anxiety associated with a new environment. This would also provide an opportunity for the nurse to encourage the patient to express feelings. The patient should avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. A quiet unwinding activity before bedtime is helpful for sleep promotion. Administering an analgesic is not an appropriate action.