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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An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
The nurse obtains adult blood pressure readings on four separate clients. Which client should have a follow-up blood pressure check within 2 months?
- A. The client whose blood pressure is 138/88 mm Hg
- B. The client whose blood pressure is 132/98 mm Hg
- C. The client whose blood pressure is 132/98 mm Hg
- D. The client whose blood pressure is 118/78 mm Hg
Correct Answer: B,C
Rationale: A blood pressure of 132/98 mm Hg indicates stage 1 hypertension (systolic 130-139 or diastolic 90-99 mm Hg), requiring follow-up within 2 months to monitor and manage. The other readings are either normal (118/78) or prehypertension (138/88), which may not require such urgent follow-up.
Which assessment finding offers the best evidence that the client can tolerate the activity involved in getting out of bed?
- A. The client's appetite has improved.
- B. The client reports a more restful sleep.
- C. The client's heart rate is stable.
- D. The client can get out of bed without assistance.
Correct Answer: C
Rationale: Stable heart rate indicates the heart can handle the increased demand of activity.
If the client develops digoxin toxicity, what would the nurse expect the client to exhibit?
- A. Anorexia and nausea
- B. Dizziness and insomnia
- C. Pinpoint pupils and double vision
- D. Ringing in the ears and itchy skin
Correct Answer: A
Rationale: Digoxin toxicity commonly causes anorexia, nausea, and vomiting due to gastrointestinal effects.
Which side effects are most closely associated with the use of nitroglycerin tablets? Select all that apply.
- A. Headache
- B. Backache
- C. Headache
- D. Jaundice
- E. Dizziness
- F. Pallor
Correct Answer: A,E
Rationale: Nitroglycerin causes vasodilation, leading to headache (due to cerebral vasodilation) and dizziness (due to hypotension). Backache, jaundice, and pallor are not typical.