Nokea
A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein thrombosis (DVT), the nurse should:
- A. Restrict fluids
- B. Encourage deep breathing
- C. Assist the client to remain sedentary
- D. Use pneumatic compression stockings
Correct Answer: D
Rationale: Pneumatic compression stockings prevent DVT post-surgery by promoting venous return and reducing stasis. Restricting fluids increases viscosity, deep breathing aids respiratory function, and remaining sedentary increases DVT risk.
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A client with bladder cancer receives intravesical chemotherapy. The nurse should:
- A. Monitor for hematuria.
- B. Restrict fluids.
- C. Administer pain medication.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.
Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it:
- A. Decreases blood pressure.
- B. Increases tubular reabsorption of water.
- C. Increases release of insulin from the pancreas.
- D. Decreases glucose production within the liver.
Correct Answer: B
Rationale: Vasopressin increases water reabsorption in the kidneys, reducing urine output in diabetes insipidus.
Which of the following factors places a client at greatest risk for skin cancer?
- A. Fair skin and history of chronic sun exposure.
- B. Caucasian race and history of hypertension.
- C. Dark skin and family history of skin cancer.
- D. Dark skin and history of hypertension.
Correct Answer: A
Rationale: Fair skin and chronic sun exposure increase skin cancer risk due to higher UV sensitivity and cumulative damage. Dark skin offers some protection.
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.