Nokea
A client is admitted to the hospital with peripheral vascular disease (PVD) of the lower extremities. He is scheduled for an amputation of the left leg. The client says, 'I've really tried to manage my condition well.' Which of the following routines should the nurse evaluate as having been appropriate for him?
- A. Resting with his legs elevated above the level of his heart
- B. Walking slowly but steadily for 30 minutes twice a day
- C. Minimizing activity
- D. Wearing antiembolism stockings at all times when out of bed
Correct Answer: B
Rationale: Walking slowly but steadily for 30 minutes twice a day promotes collateral circulation and maintains muscle strength in PVD, an appropriate self-management strategy. Elevating legs above the heart is contraindicated in arterial insufficiency, minimizing activity worsens ischemia, and antiembolism stockings are more suited for venous issues.
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Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply.
- A. Epinephrine
- B. Acetaminophen
- C. Diphenhydramine
- D. Hydrocortisone
- E. Pantoprazole
Correct Answer: A,C,D
Rationale: Epinephrine treats severe allergic reactions (anaphylaxis), diphenhydramine manages mild to moderate allergic symptoms, and hydrocortisone reduces inflammation in allergic reactions. Acetaminophen is for fever or pain, and pantoprazole is for gastric issues, not allergic reactions.
A nurse is caring for a client with lung cancer who develops syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory finding should the nurse expect?
- A. Serum sodium of 128 mEq/L.
- B. Serum potassium of 5.5 mEq/L.
- C. Serum calcium of 11.0 mg/dL.
- D. Serum glucose of 200 mg/dL.
Correct Answer: A
Rationale: SIADH causes water retention, diluting serum sodium, so a low sodium level (128 mEq/L) is expected due to the inappropriate secretion of antidiuretic hormone.
A client scheduled for a cholecystectomy expresses fear about postoperative pain. Which nursing action is most appropriate?
- A. Administer preoperative analgesics as ordered.
- B. Teach the client about pain management options.
- C. Reassure the client that pain is minimal after surgery.
- D. Refer the client to a pain management specialist.
Correct Answer: B
Rationale: Teaching the client about pain management options, such as PCA or oral analgesics, empowers them to understand and cope with postoperative pain, reducing anxiety. Administering analgesics may not be ordered preoperatively, and reassurance without education is inadequate.
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
- A. Checking urine for bright blood and a dark smoky color
- B. Daily walking as a good exercise
- C. Using garlic and ginger, which may decrease bleeding time
- D. Performing foot/leg exercises and walking around the airplane cabin on long flights
- E. Prevention as the best treatment for DVT
- F. Avoiding surface bumps because the skin is prone to injury
Correct Answer: A,B,D,F
Rationale: Rationales: A) Monitoring urine for bleeding is essential on anticoagulants. B) Daily walking promotes circulation, preventing DVT recurrence. D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy. C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.
The nurse is caring for a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
- A. Attempt to carefully remove the glass from the eye
- B. Reassure the client that everything is okay
- C. Administer a sedative for pain relief
- D. Advise the client to remain in a sitting position until a specialist arrives
Correct Answer: D
Rationale: A foreign object like glass in the eye requires specialist intervention. Keeping the client in a sitting position minimizes further damage until a specialist evaluates. Attempting removal, false reassurance, or sedation without specialist input is inappropriate.