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A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
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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.
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 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 client with peripheral artery disease (PAD) makes the following statements to the nurse. Which indicates the need for further teaching?
- A. I should avoid using heating pads on my legs
- B. I need to walk until I feel pain, then rest
- C. I should keep my legs elevated when resting
- D. It's going to be really hard but I will stop smoking
Correct Answer: A
Rationale: Clients with PAD should avoid heating pads due to decreased skin sensitivity, which can lead to burns. This statement shows understanding, so no further teaching is needed for it. The other statements align with proper PAD management.
A client is postoperative after surgery to repair a fractured hip and has a history of atrial fibrillation. What action by the nurse is most important to prevent wound infections?
- A. Performing hand hygiene before client contact
- B. Changing the surgical dressing daily
- C. Monitoring the client's daily white blood cell count
- D. Administering prophylactic antibiotics
Correct Answer: A
Rationale: Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique, but hand hygiene is the most critical step. Assessing vital signs and white blood cell count will not prevent infection.