Nokea
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
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A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
The nurse is caring for a client who had a forceps-assisted vaginal birth and is reporting severe vaginal pain and fullness. The nurse notes the fundus is firm and midline with a scant amount of lochia rubra. The client is most likely experiencing
- A. uterine atony
- B. vaginal hematoma
- C. cervical lacerations
- D. inversion of the uterus
Correct Answer: B
Rationale: Severe vaginal pain and fullness with a firm fundus and scant lochia suggest a vaginal hematoma (B). Uterine atony (A) causes heavy bleeding, cervical lacerations (C) cause bleeding, and uterine inversion (D) involves a displaced fundus.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.