Nokea
A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
- A. Elevate the affected leg on a pillow.
- B. Apply a warm compress to the affected leg.
- C. Perform passive range-of-motion exercises on the affected leg.
- D. Encourage the client to ambulate frequently.
Correct Answer: A
Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.
You may also like to solve these questions
A client with a history of alcohol abuse is admitted with acute pancreatitis. Which assessment finding requires immediate intervention?
- A. Amylase of 120 U/L.
- B. Lipase of 150 U/L.
- C. Calcium of 8.5 mg/dL.
- D. Temperature of 101°F (38.3°C).
Correct Answer: D
Rationale: In a client with acute pancreatitis and a history of alcohol abuse, a temperature of 101°F (38.3°C) can indicate infection, which is a serious complication requiring immediate intervention. Elevated amylase and lipase levels are common in acute pancreatitis but do not directly indicate the need for urgent intervention. A calcium level of 8.5 mg/dL is within the normal range and does not require immediate action in this context.
The healthcare provider is developing a health education program for pregnant women on the importance of prenatal care. Which topic should be prioritized?
- A. the benefits of breastfeeding
- B. nutrition and weight gain during pregnancy
- C. the stages of fetal development
- D. signs and symptoms of preterm labor
Correct Answer: D
Rationale: Prioritizing the discussion on signs and symptoms of preterm labor is essential as it empowers pregnant women to recognize warning signs promptly and seek medical assistance to prevent potential complications. Understanding preterm labor signs, such as abdominal cramping, pelvic pressure, or vaginal bleeding, can lead to early intervention and improve maternal and fetal outcomes. While topics like breastfeeding benefits, nutrition during pregnancy, and fetal development stages are important, identifying signs of preterm labor takes precedence due to its immediate impact on maternal and fetal well-being.
A teenage boy with a history of recurring atopic dermatitis (eczema) tells the school nurse that he wants to play high school football. Which action should the nurse take?
- A. encourage the teenager to join the swim team instead of the football team
- B. notify the parents of the problems associated with perspiration for those with eczema
- C. tell the teenager to shower with a non-perfumed soap immediately after practice
- D. inform the football coach of the teenager's skin condition and its manifestations
Correct Answer: C
Rationale: The correct action for the nurse to take is to advise the teenager to shower with a non-perfumed soap immediately after practice. This recommendation can help reduce the risk of eczema flare-ups by removing sweat and irritants from the skin. Choice A is incorrect as it does not address the specific concerns related to eczema and football. Choice B, notifying the parents of perspiration problems, is not as direct as instructing the teenager on proper skincare. Choice D, informing the football coach, is not the most immediate and relevant action to address the teenager's individual needs.
The nurse is teaching a group of high school adolescents about safety associated with traumatic injuries. Which factor causing spinal cord injuries should the nurse discuss with the adolescents?
- A. motor vehicle accidents
- B. violent assault
- C. sports injuries
- D. falls
Correct Answer: A
Rationale: The correct answer is A: motor vehicle accidents. Motor vehicle accidents are a significant cause of spinal cord injuries among adolescents due to the high impact forces involved. While violent assault, sports injuries, and falls can also lead to spinal cord injuries, statistics show that motor vehicle accidents are a leading cause in this age group. Educating adolescents about the risks and preventive measures related to motor vehicle accidents is crucial in promoting their safety and well-being.
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
- A. Supine with the foot of the bed raised.
- B. On the left side with legs elevated.
- C. On the right side with legs elevated.
- D. Prone with head elevated.
Correct Answer: A
Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.