Nokea
A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply.
- A. Ice packs to the right leg
- B. Elevation of the right leg
- C. Hourly calf measurements
- D. Vigorous range of motion to the right leg
- E. Reposition the client carefully at regular intervals
Correct Answer: B,E
Rationale: Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus.
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The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.
The nurse is assessing a client with suspected Bell's palsy. Which finding supports this diagnosis?
- A. Unilateral facial weakness
- B. Bilateral hand tremors
- C. Severe headache
- D. Neck stiffness
Correct Answer: A
Rationale: Unilateral facial weakness is the primary symptom of Bell's palsy, caused by facial nerve inflammation or compression.
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
- A. The client has refrigerated foods labelled with an expiration date.
- B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
- C. The client uses the FIFO method for insuring food safety.
- D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.
Which of the following suggestions should the nurse give to an adolescent football player with Osgood-Schlatter disease of the left knee?
- A. Apply ice on the knee after playing.
- B. Use crutches until healing has occurred.
- C. Stop playing until healing has occurred.
- D. Make an appointment with a physical therapist.
Correct Answer: A
Rationale: Applying ice after activity reduces inflammation and pain in Osgood-Schlatter disease.
The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
- A. Prone
- B. Supine
- C. Semi-Fowler's on the back
- D. Low Fowler's on the right side
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.