Nokea
A 72-year-old man had a total hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan's sign. Which of the following will be included in the initial care of this man?
- A. Warm packs to the left leg
- B. Vigorous massage of the left leg
- C. Placing the left leg in a dependent position
- D. Performing range of motion exercises to the left leg
Correct Answer: C
Rationale: Placing the leg in a dependent position promotes venous return and reduces swelling in suspected deep vein thrombosis. Warm packs, massage, or range of motion may dislodge a clot, increasing embolism risk.
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Which assessment finding is most closely correlated with an evolving MI?
- A. Nausea
- B. Facial flushing
- C. Severe headache
- D. Coughing up pink-tinged mucus
Correct Answer: A
Rationale: Nausea is a common symptom of myocardial infarction due to vagal stimulation or pain-induced stress response.
Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
- A. Diminished pedal pulses
- B. Color changes in the extremities when elevated
- C. Red, shiny skin
- D. Coolness and pallor in the leg
Correct Answer: C
Rationale: Red, shiny skin is a common sign of thrombophlebitis due to inflammation and impaired venous return. Diminished pulses, color changes with elevation, or coolness are more indicative of arterial issues.
Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.
When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.