Nokea
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.
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A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.
- A. Abduction and adduction
- B. Hyperextension
- C. Supination and pronation
- D. Flexion and extension
- E. Rotation
Correct Answer: C,D
Rationale: Elbow ROM includes supination/pronation (C) and flexion/extension (D). Abduction/adduction (A), hyperextension (B), and rotation (E) are not applicable to the elbow joint.
Nimotop (Nimodipine) is ordered for the client with a ruptured cerebral aneurysm. The nurse recognizes that the desired effect of this drug is to:
- A. Prevent the influx of calcium into cells
- B. Restore the client's blood pressure to a normal reading
- C. Prevent the inflammatory process
- D. Dissolve the clot that has formed
Correct Answer: A
Rationale: Nimodipine is a calcium channel blocker that prevents calcium influx into vascular smooth muscle cells, reducing vasospasm in cerebral arteries, which is critical in managing ruptured cerebral aneurysms.
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order
- B. Try to obtain samples for the client to take home
- C. Perform discharge teaching regarding this drug
- D. Consult social services for financial assistance with obtaining the drug
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which can exacerbate ischemia. The nurse should question the prescription.
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron and recommended for iron-deficiency anemia.