A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?
- A. Bed rest, with bathroom privileges only
- B. Bed rest, keeping the affected extremity flat
- C. Bed rest, with elevation of the affected extremity
- D. Bed rest, with the affected extremity in a dependent position
Correct Answer: C
Rationale: The correct answer is C: Bed rest, with elevation of the affected extremity. Elevating the affected extremity is crucial in managing thrombophlebitis as it helps reduce swelling and promotes venous return. By elevating the affected extremity, the gravitational force assists in venous blood flow back to the heart, thereby reducing the risk of complications associated with thrombophlebitis. Choices A, B, and D are incorrect because they do not address the need for elevation, which is specifically beneficial in the management of thrombophlebitis.
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What predisposing factor most likely contributed to the proximal end of the femur fracture in a 62-year-old woman who lives alone and tripped on a rug in her home?
- A. Failing eyesight leading to an unsafe environment
- B. Renal osteodystrophy from chronic kidney disease (CKD)
- C. Osteoporosis from declining hormone levels
- D. Cerebral vessel changes causing transient ischemic attacks
Correct Answer: C
Rationale: The most likely predisposing factor contributing to the proximal end of the femur fracture in a 62-year-old woman is osteoporosis resulting from declining hormone levels. Osteoporosis weakens the bones, making them more susceptible to fractures, especially in older adults, particularly women. In this case, the fracture can be attributed to the bone density loss associated with osteoporosis, which is a common concern in postmenopausal women. Choices A, B, and D are less likely to have directly contributed to the femur fracture in this scenario. Failing eyesight may increase the risk of falls but does not directly weaken the bones. Renal osteodystrophy affects bone health but is less common in this age group. Cerebral vessel changes causing transient ischemic attacks are related to vascular issues, not bone strength.
The healthcare provider is evaluating the effects of care for a client with deep vein thrombosis (DVT). Which limb observations should the provider note as indicating the least success in meeting the outcome criteria for this problem?
- A. Pedal edema that is 3+
- B. Slight residual calf tenderness
- C. Skin warm, equal temperature in both legs
- D. Calf girth 1/8 inch larger than the unaffected limb
Correct Answer: A
Rationale: Significant pedal edema, indicated by 3+, suggests ongoing or worsening venous insufficiency. This can be a sign that the care provided has not been effective in managing the deep vein thrombosis (DVT) and the associated complications. Monitoring and addressing pedal edema is crucial in the evaluation of DVT treatment outcomes and overall patient care. Choices B, C, and D are not indicative of the least success in meeting the outcome criteria for DVT. Slight residual calf tenderness, skin warmth, and a slightly larger calf girth do not necessarily point towards treatment failure or lack of improvement in DVT management.
Drugs that may cause anticholinergic effects include:
- A. Diphenhydramine
- B. Atenolol
- C. Lisinopril
- D. All of the above
Correct Answer: A
Rationale: Choice A is correct because diphenhydramine has strong anticholinergic effects (e.g., confusion, dry mouth), risky in the elderly, per Beers Criteria. Choice B is incorrect as atenolol (beta blocker) lacks anticholinergic action. Choice C is wrong because lisinopril (ACE inhibitor) doesn't affect cholinergic systems. Choice D is incorrect since only diphenhydramine applies.
Signs of tolerance include:
- A. Needing higher doses for the same effect
- B. Reduced side effects over time
- C. Increased sensitivity to the drug
- D. All of the above
Correct Answer: A
Rationale: Choice A is correct because tolerance is defined by needing more drug for the same effect due to body adaptation, per pharmacokinetic principles. Choice B is incorrect as reduced side effects may occur but aren't the definition. Choice C is wrong because sensitivity decreases, not increases. Choice D is incorrect since only A fits.
A client with a history of heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?
- A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
- B. Increase your fluid intake to at least 3 liters per day.
- C. Report any weight loss of more than 2 pounds in a week.
- D. Take the medication with meals to avoid gastrointestinal upset.
Correct Answer: A
Rationale: The correct instruction for discharge teaching regarding digoxin (Lanoxin) is to advise the client to take their pulse before each dose and to hold the medication if their pulse is below 60 beats per minute. Digoxin can cause bradycardia, so monitoring the pulse is crucial to prevent potential complications. Choice B is incorrect because excessive fluid intake can lead to fluid overload, worsening heart failure. Choice C is not directly related to digoxin therapy. Choice D is inaccurate as digoxin is usually taken on an empty stomach to facilitate absorption.