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A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
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A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client states the drug is dangerous. What action by the nurse is best?
- A. Assess the reason behind the client's fear
- B. Remind the client about laboratory monitoring
- C. Tell the client drugs are safer today than before
- D. Warn the client about consequences of noncompliance
Correct Answer: A
Rationale: The first step is to assess the reason behind the client's fear, which may be related to a past experience. Addressing the specific concern is critical for effective teaching and compliance. The other options do not address the client's fear directly.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client's weight has decreased significantly since the last visit. What action by the nurse is best?
- A. Ask if the weight loss was intentional
- B. Encourage a high-protein, high-fiber diet
- C. Measure for new compression stockings
- D. Review a 3-day food recall diary
Correct Answer: C
Rationale: Compression stockings must fit correctly to be effective. After significant weight loss, the client should be re-measured for new stockings. The other options are appropriate but less critical.
A student nurse asks what essential hypertension is. What response by the registered nurse is best?
- A. It is caused by another disease
- B. It means it must be treated immediately
- C. It has no specific cause
- D. It refers to severe and life-threatening hypertension
Correct Answer: C
Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension caused by another disease is secondary hypertension. Severe, life-threatening hypertension is malignant hypertension.
A nurse is prioritizing care for four clients. Which client should the nurse see first?
- A. A client who needs assistance to ambulate
- B. A client with a new prescription for captopril (Capoten)
- C. A hypertensive client with a blood pressure of 182/92 mm Hg
- D. A client who needs pain medication prior to a dressing change
Correct Answer: B
Rationale: Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falls if the client attempts to get up without assistance. The other clients' conditions are less urgent.