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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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What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: Rationale:
C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention.
Summary:
A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary.
B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances.
D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.
A patient with hyperthyroidism is to receive radioactive iodine therapy. What information should the nurse include in the patient teaching plan?
- A. Avoid close contact with pregnant women for one week.
- B. Take iodine supplement daily.
- C. Restrict fluid intake to 1 liter per day.
- D. Use disposable utensils for all meals.
Correct Answer: A
Rationale: The correct answer is A. The rationale is that radioactive iodine therapy can harm a developing fetus, so patients should avoid close contact with pregnant women for one week. Choice B is incorrect as iodine supplements can interfere with the therapy. Choice C is incorrect as fluid intake should not be restricted unless specifically advised by the healthcare provider. Choice D is incorrect as there is no need to use disposable utensils for all meals.
A patient with coronary artery disease (CAD) is prescribed a statin medication. What should the nurse include in the patient education?
- A. Take the medication with food.
- B. Report any muscle pain or weakness.
- C. Increase intake of grapefruit juice.
- D. Avoid foods high in potassium.
Correct Answer: B
Rationale: Step 1: Statins can cause muscle pain or weakness as a side effect.
Step 2: Prompt reporting of muscle pain or weakness is crucial to address potential myopathy or rhabdomyolysis.
Step 3: Nurse should educate patient to report any muscle symptoms promptly for timely intervention and prevention of complications.
Summary: Option B is correct as it emphasizes the importance of monitoring and reporting potential side effects of statins. Options A, C, and D are incorrect as taking with food, increasing grapefruit juice intake, and avoiding potassium-rich foods are not relevant considerations for statin therapy.
A patient with a diagnosis of peptic ulcer disease is prescribed omeprazole. When should the patient take this medication for optimal effectiveness?
- A. With meals
- B. At bedtime
- C. Before meals
- D. After meals
Correct Answer: C
Rationale: The correct answer is C: Before meals. Omeprazole is a proton pump inhibitor that works by reducing stomach acid production. Taking it before meals allows the medication to be most effective in inhibiting the proton pumps before they are stimulated by food intake. This timing optimizes the drug's ability to reduce acid secretion during the digestion process.
Choice A (With meals) is incorrect because taking omeprazole with meals may reduce its effectiveness as it will not have enough time to inhibit acid production before food intake. Choice B (At bedtime) is also incorrect as omeprazole works best when taken before meals to prevent acid production. Choice D (After meals) is incorrect because waiting until after meals to take omeprazole means that acid production has already been stimulated by the food consumed, reducing the drug's effectiveness in inhibiting acid secretion.
What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fiber diet.
- C. Clean the perianal area carefully after every bowel movement.
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: The correct answer is C: Clean the perianal area carefully after every bowel movement. This is important to prevent skin breakdown and infection due to the potential side effect of radiation-induced diarrhea. By maintaining good hygiene in the perianal area, the patient can reduce the risk of complications such as skin irritation and infection.
Choice A is incorrect because testing stools for the presence of blood is not directly related to preventing complications from external-beam radiation.
Choice B is incorrect because while a high-residue, high-fiber diet may be beneficial for some cancer patients, it is not specifically recommended to prevent complications from radiation therapy in this case.
Choice D is incorrect because inspecting the mouth and throat daily for thrush is more relevant for patients receiving chemotherapy or immunosuppressive therapy, not specifically for those undergoing external-beam radiation.