Nokea
A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Notify the healthcare provider immediately. This is the priority action because the client is experiencing severe pain, swelling, warmth, and redness in the leg, which are signs of potential deep vein thrombosis (DVT) or other serious complications postoperatively. The healthcare provider needs to be informed promptly to assess and initiate appropriate treatment to prevent further complications.
A: Applying a warm compress may worsen the condition if it is DVT, as heat can promote clot formation.
B: Elevating the leg on pillows may not address the underlying cause of the symptoms and delay necessary intervention.
C: Measuring the circumference of the leg may provide some information, but it is not as urgent as notifying the healthcare provider for immediate assessment and intervention.
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A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?
- A. Avoid foods high in vitamin K.
- B. Increase intake of dairy products.
- C. Limit intake of citrus fruits.
- D. Avoid high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a vitamin K antagonist, so consuming high-vitamin K foods can counteract its effects. By avoiding such foods, the medication can work effectively in preventing further blood clot formation. Choice B is incorrect because dairy products do not directly interact with warfarin. Choice C is incorrect as citrus fruits do not have a significant impact on warfarin therapy. Choice D is incorrect as sodium intake is not directly related to the action of warfarin.
A patient with tuberculosis is started on rifampin. What advice should the nurse provide?
- A. Limit intake of green leafy vegetables.
- B. Expect orange-red discoloration of body fluids.
- C. Avoid exposure to sunlight.
- D. Take the medication with antacids.
Correct Answer: B
Rationale: The correct answer is B: Expect orange-red discoloration of body fluids. Rifampin is known to cause a harmless side effect of discoloration of body fluids, such as urine, sweat, saliva, and tears, turning them orange-red. This is a common occurrence and should be expected by the patient.
Incorrect choices:
A: Limit intake of green leafy vegetables - This advice is not necessary with rifampin.
C: Avoid exposure to sunlight - There is no direct association between rifampin and sunlight exposure.
D: Take the medication with antacids - Rifampin should not be taken with antacids as they can interfere with its absorption.
In summary, the correct answer is B because it aligns with a known side effect of rifampin, while the other choices are not relevant to the medication.
A client with cirrhosis is at risk for bleeding. Which laboratory test is most important to monitor?
- A. Blood glucose
- B. Serum creatinine
- C. Prothrombin time (PT)
- D. Electrolytes
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). In cirrhosis, the liver's ability to produce clotting factors is impaired, leading to a higher risk of bleeding. Monitoring PT helps assess the liver's synthetic function and the blood's ability to clot. Abnormal PT values indicate a higher bleeding risk and guide interventions like vitamin K or blood products. Blood glucose (A), serum creatinine (B), and electrolytes (D) do not directly reflect the liver's synthetic function or clotting status in cirrhosis, making them less relevant for monitoring bleeding risk.
What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. Bleeding time
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is used to monitor the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the PTT results. Monitoring PTT helps to ensure that the patient's blood is within the therapeutic range for anticoagulation.
A: Prothrombin time (PT) is used to monitor warfarin therapy, which affects the extrinsic pathway of the coagulation cascade.
C: Bleeding time is not typically used to monitor heparin therapy effectiveness.
D: Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not directly reflect the effectiveness of heparin therapy in preventing or treating DVT.