Nokea
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Edema
- D. Pallor
Correct Answer: C
Rationale: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.
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The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?
- A. Fried fish sandwich and potato salad
- B. Baked turkey and salad
- C. Biscuits with sausage gravy and sliced tomatoes
- D. Barbecued ribs and canned baked beans
Correct Answer: B
Rationale: Baked turkey and salad: This is a healthy choice, as baked turkey is low in fat, and a salad provides nutrients without excessive fat or cholesterol, supporting heart health.
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?
- A. Troponin T
- B. Creatinine phosphokinase
- C. Myoglobin
- D. Creatinine kinase-MB
Correct Answer: A
Rationale: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.
A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?
- A. Keep the affected knee flexed.
- B. Encourage increased fluid intake.
- C. Massage the client's calf on the affected side.
- D. Promote bed rest for 5-10 days.
Correct Answer: B
Rationale: Encourage increased fluid intake. Encouraging fluid intake helps to prevent dehydration, which is a risk factor for blood clot formation. Adequate hydration helps keep the blood less viscous and reduces the risk of DVT.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?
- A. Why have you changed your mind about the surgery?
- B. Your provider would not have scheduled the surgery unless you needed it.
- C. I will call your doctor and have him discuss your surgery with you.
- D. Bypass surgery must be very frightening for you.
Correct Answer: D
Rationale: Bypass surgery must be very frightening for you. This response uses a therapeutic communication technique by acknowledging the client's emotions and opening the conversation for further exploration of their concerns.
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. Which of the following actions should the nurse anticipate when notifying the provider of this finding?
- A. Obtain platelet aggregation studies to confirm DVT
- B. Schedule deep tissue massage with physical therapy.
- C. Arrange for a venous duplex ultrasound.
- D. Monitor Homan's sign.
Correct Answer: C
Rationale: Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.