A client calls the nurse with a complaint of sudden deep thr...

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

A. Suggest isometric exercises
B. Maintain the client on bed rest
C. Ambulate for several minutes
D. Apply ice to the extremity

Correct Answer: B

Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

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The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.

A. Check gastric residual every 12 hours
B. Keep head of the bed at â‰¥30 degrees
C. Maintain endotracheal cuff pressure
D. Monitor for abdominal distension every 4 hours
E. Use caution when administering sedatives

Correct Answer: B,C,D,E

Rationale: Elevating the head of the bed (â‰¥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.

The nurse is interacting with a client who has just been told she is HIV positive. The client asks the nurse when she will die. What should the nurse plan to include when replying?

A. HIV positive means that the client has antibodies against the virus. It does not mean that the client has AIDS. Most people do not develop AIDS or die for many years.
B. Most persons who are HIV positive live 5 to 10 years with aggressive treatment.
C. Life expectancy depends on whether there is further exposure to the virus.
D. The progression from HIV positive to full-blown AIDS is usually quite rapid.

Correct Answer: A

Rationale: HIV positivity indicates antibodies, not AIDS; with modern antiretroviral therapy, progression is slow, and many live for decades, unlike rapid progression or fixed timelines.

The nurse is collecting data from assigned clients. It would require follow-up if a

A. 3-week-old client has an anterior fontanel that pulsates slightly and bulges when crying
B. 4-week-old client has a posterior fontanel that is soft and flat to palpation
C. 6-month-old client had a birth weight of 7 lb 3 oz (3300 g) and now weighs 12 lb (5400 g)
D. 12-month-old client had a birth weight of 6 lb 4 oz (2800 g) and now weighs 19 lb 2 oz (8700 g)

Correct Answer: C

Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply.

A. I should have our home inspected for the source of lead.
B. I will vacuum our hard-surface floors daily.
C. I will wash my child's hands often, especially before eating.
D. We should use hot water from the tap for cooking.
E. We will have to return for a follow-up lead level.

Correct Answer: A,C,E

Rationale: Inspecting the home identifies lead sources (e.g., paint, dust). Frequent hand washing reduces ingestion of lead dust. Follow-up testing monitors levels. Vacuuming may spread lead dust; wet mopping is preferred. Hot water can leach lead from pipes; cold water is safer.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

A. I need to avoid taking medicines like ibuprofen without a prescription.
B. I should avoid drinking excess coffee or cola.
C. I should enroll in a smoking cessation program.
D. I should reduce or eliminate my intake of alcoholic beverages.
E. I will eliminate whole wheat foods, like breads and cereals, from my diet.

Correct Answer: A,B,C,D

Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.