Nokea
A female client is admitted to the hospital with obesity and deep vein thrombophlebitis (DVT) of the right leg. She weighs 275 pounds. Which of the following factors is least related to her diagnosis?
- A. She has been taking oral estrogens for the last three years.
- B. She smokes two packs of cigarettes daily.
- C. Her right femur was fractured recently.
- D. She is 30 years old.
Correct Answer: D
Rationale: Age (30 years) is the least related to DVT risk compared to estrogen use, smoking, and recent fracture, which are known risk factors for thrombosis.
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Which nursing response is most appropriate at this time?
- A. Cleaning up the floor and saying nothing
- B. Finding out what food would be preferred
- C. Allowing the client to vent his or her feelings
- D. Leaving the client alone until feeling better
Correct Answer: C
Rationale: Allowing the client to vent feelings addresses emotional distress and supports coping.
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?
- A. The client has a BP of 110/70.
- B. The client has an apical pulse of 56.
- C. The client is complaining of a headache.
- D. The client's potassium level is 4.5 mEq/L.
Correct Answer: B
Rationale: Beta blockers slow heart rate; a pulse of 56 (B) may indicate bradycardia, warranting caution. BP 110/70 (A), headache (C), and normal potassium (D) are not contraindications.
The nurse is teaching an adult who has angina about taking nitroglycerin. The nurse tells him he will know the nitroglycerin is effective when:
- A. he experiences tingling under the tongue.
- B. his pulse rate increases.
- C. his pain subsides.
- D. his activity tolerance increases.
Correct Answer: C
Rationale: The effectiveness of nitroglycerin is indicated by the relief of anginal pain. Tingling, increased pulse rate, or improved activity tolerance are not direct indicators of its effectiveness.
Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.