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A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
- A. The client will not disturb the intravenous infusion.
- B. The client will comply with dietary restrictions.
- C. The client will not experience bleeding.
- D. The client will keep the right leg elevated on two pillows.
Correct Answer: C
Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.
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A patient has developed a paralytic ileus following recent abdominal surgery. What is the most important nursing action when caring for this patient?
- A. Monitor bowel sounds every hour
- B. Maintain the patient on strict bed rest
- C. Ensure the nasogastric tube is functioning
- D. Ensure that the patient is given a clear liquid diet
Correct Answer: C
Rationale: Ensuring that the nasogastric tube is functioning is the most important nursing action when caring for a patient with a paralytic ileus. A paralytic ileus is a condition where there is a temporary paralysis of the intestine, leading to a lack of bowel motility. This can result in a buildup of gas and fluids in the intestines, causing abdominal distension, pain, and potential complications.
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?
- A. Deep vein thrombosis
- B. Endocarditis
- C. Atherosclerosis
- D. Shock
Correct Answer: B
Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.
The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?
- A. Cardiomyopathy
- B. Paroxysmal nocturnal dyspnea
- C. High-output failure
- D. Multisystem heart failure
Correct Answer: B
Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.
The nurse is determining the type of arthritis a patient is experiencing. Which assessment finding would be present if the patient has rheumatoid arthritis?
- A. Stiffness is relieved by activity
- B. Health history includes weight loss and fever
- C. Abnormal joint findings are limited to the hands
- D. Heberden’s nodes are located on the finger joints
Correct Answer: B
Rationale: In rheumatoid arthritis, the health history often includes systemic symptoms such as weight loss and fever. Rheumatoid arthritis is a chronic inflammatory autoimmune disease that affects multiple joints symmetrically. Unlike osteoarthritis where joint stiffness is often relieved by activity, stiffness in rheumatoid arthritis is typically worse in the morning and after inactivity. In rheumatoid arthritis, joint deformities can occur in various joints, not just limited to the hands. Heberden's nodes are characteristic of osteoarthritis, not rheumatoid arthritis.
An adult client is experiencing paroxysmal supraventricular tachycardia. Which nursing interventions are appropriate based on the data provided? Select all that apply.
- A. Initiate oxygen therapy
- B. Prepare for cardioversion
- C. Begin anticoagulation therapy as prescribed
- D. Administer intravenous adenosine as prescribed
Correct Answer: A
Rationale: A. Initiate oxygen therapy: Providing oxygen therapy is appropriate to ensure adequate oxygenation and tissue perfusion during episodes of paroxysmal supraventricular tachycardia.