Nokea
A client has been on prolonged bedrest following surgery. The nurse notes that the patient has pain in the right calf on palpation with dorsiflexion of the ankle. Which of the following causes does the nurse suspect?
- A. Arthritis
- B. Muscle strain
- C. Compartment syndrome
- D. Deep vein thrombosis
Correct Answer: D
Rationale: Calf pain with dorsiflexion (Homan's sign) suggests deep vein thrombosis (D), common after prolonged bedrest. Arthritis (A), muscle strain (B), and compartment syndrome (C) present differently.
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A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A. Taking hourly blood pressures with mechanical cuff
- B. Encouraging fluid intake of at least 200 mL per hour
- C. Position in high Fowler's with knee gatch raised
- D. Administering Tylenol as ordered
Correct Answer: B
Rationale: Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.
- A. After I apply the stocking, I roll the top back down about 2 inches to hold the stockings in place.
- B. I remove the stocking and reapply about every day or two.
- C. To apply, I turn the stocking inside out while holding onto the toe.
- D. I apply a small amount of baby powder to my legs before applying the stockings.
- E. These stockings help prevent blood clots.
Correct Answer: A,B,D
Rationale: Rolling the top down (A) can impede circulation, removing stockings every 1-2 days (B) is too infrequent (should be every 8 hours), and baby powder (D) can cause skin irritation. Turning the stocking inside out (C) and preventing clots (E) are correct.