How should a healthcare provider monitor a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg swelling
- B. Encourage ambulation
- C. Check for redness
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct way for a healthcare provider to monitor a patient with suspected deep vein thrombosis (DVT) is to check for leg swelling. Leg swelling is a common symptom of DVT and monitoring for this sign is crucial for early detection and intervention. Encouraging ambulation may be beneficial for preventing DVT but is not the recommended method for monitoring an existing condition. Checking for redness may be useful in cases of superficial thrombophlebitis but is not specific to DVT. Monitoring oxygen saturation is more relevant for respiratory or cardiovascular conditions, not for DVT.
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A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Apply a dry dressing.
- B. Cleanse the wound with normal saline.
- C. Perform debridement as needed.
- D. Apply a hydrocolloid dressing.
Correct Answer: D
Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.
How should a healthcare professional manage a patient with non-compliance to hypertension medication?
- A. Provide education on medication
- B. Refer the patient to a specialist
- C. Discontinue the medication
- D. Reassess the patient in 6 months
Correct Answer: A
Rationale: Providing education on medication is crucial when managing a patient with non-compliance to hypertension medication. By educating the patient on the importance of adherence, potential side effects, and the impact of uncontrolled hypertension, healthcare professionals can help improve the patient's understanding and compliance. Referring the patient to a specialist (Choice B) may be necessary in some cases but should not be the first step. Discontinuing the medication (Choice C) without exploring reasons for non-compliance and providing education can worsen the patient's condition. Reassessing the patient in 6 months (Choice D) is important but should be accompanied by interventions to address non-compliance in the interim.
What is the priority nursing intervention for a patient experiencing a myocardial infarction?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Administer morphine
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.
A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct Answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself every morning.
- B. I should drink 2 liters of water each day.
- C. I should avoid all physical activity.
- D. I should take an extra dose of diuretic if I gain 2 pounds in a day.
Correct Answer: A
Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.