Nokea
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
- A. Elevate leg on 2 pillows
- B. Apply support stockings
- C. Apply warm compresses
- D. Maintain complete bed rest
Correct Answer: A
Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.
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In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is:
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: The most appropriate advice for an adolescent with acne is to eat a balanced diet for their age. A balanced diet that includes a variety of nutrients is essential for overall health, including skin health. While protein and Vitamin A are important for skin health, focusing solely on increasing these nutrients may not address the overall dietary needs. Similarly, solely decreasing fatty foods or avoiding caffeine may not be the most effective advice for managing acne. Therefore, the best advice is to promote a balanced diet tailored to the adolescent's age.
When caring for premature newborns in an intensive care setting, a nurse carefully monitors oxygen concentration. What is the most common complication of this therapy?
- A. Intraventricular hemorrhage
- B. Retinopathy of prematurity
- C. Bronchopulmonary dysplasia
- D. Necrotizing enterocolitis
Correct Answer: B
Rationale: Retinopathy of prematurity is the most common complication in premature infants exposed to high concentrations of oxygen. This condition leads to abnormal blood vessel growth in the retina, which can potentially result in blindness if not managed promptly. Intraventricular hemorrhage, though a significant concern in premature infants, is not directly related to oxygen therapy. Bronchopulmonary dysplasia is primarily associated with mechanical ventilation and oxygen exposure over time, not specifically with oxygen concentration monitoring. Necrotizing enterocolitis is more linked to gastrointestinal issues and is not the most common complication of oxygen therapy in premature newborns.
Which of the following activities is an example of tertiary prevention?
- A. Health education
- B. Regular exercise
- C. Screening tests
- D. Physical therapy
Correct Answer: D
Rationale: The correct answer is D, physical therapy. Tertiary prevention focuses on rehabilitation and treatment to prevent complications from a disease or injury. Physical therapy falls under this category as it helps individuals recover and improve functionality after an illness or injury. Choices A, B, and C are not examples of tertiary prevention. Health education (choice A) is more aligned with primary prevention by promoting healthy behaviors to prevent disease onset. Regular exercise (choice B) can be categorized under both primary and secondary prevention as it aims to prevent disease development and detect conditions early. Screening tests (choice C) are part of secondary prevention as they aim to detect diseases at an early stage for prompt treatment.
A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hypoglycemia
- C. Hyperkalemia
- D. Tendonitis
Correct Answer: D
Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.