Nokea
A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?
- A. Presence of bruising on the arms and legs
- B. The client reports new onset of severe headache
- C. The client reports pain and swelling in the calf
- D. The client reports increased urination
Correct Answer: C
Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.
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A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. diaphoresis with decreased urinary output
- B. increased heart rate with increased respirations
- C. improved respiratory status and increased urinary output
- D. decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.
A client who has received treatment for kidney stones should be reminded to increase intake of which of the following?
- A. Tea
- B. Sodium
- C. Water
- D. Protein
Correct Answer: C
Rationale: The correct answer is C: Water. Increasing water intake helps prevent the formation of new kidney stones by diluting the urine. Tea (Choice A) contains oxalates, which can contribute to kidney stone formation. Sodium (Choice B) should be limited to prevent the risk of certain types of kidney stones. Protein (Choice D) intake should be moderate as excessive protein consumption may increase the risk of kidney stones. Therefore, advising the client to increase water intake is the most appropriate recommendation to prevent the recurrence of kidney stones.
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. Every four to six hours
- B. Continuously
- C. In a bolus
- D. Every hour
Correct Answer: B
Rationale: When administering enteral feeding through a jejunostomy tube, the nurse should administer the formula continuously. Continuous feeding is essential for optimal nutrient absorption and to prevent complications. Administering the formula every four to six hours, in a bolus, or every hour may lead to inadequate nutrition, improper absorption, and an increased risk of complications such as aspiration or dumping syndrome, making these choices incorrect.
A client is being treated for congestive heart failure with furosemide (Lasix). Which of these findings would be most concerning to the nurse?
- A. Increased urine output
- B. Decreased appetite
- C. Weight loss of 2 kg in 24 hours
- D. Blood pressure of 140/90 mm Hg
Correct Answer: C
Rationale: The correct answer is C. A rapid weight loss of 2 kg in 24 hours suggests significant fluid loss, which is concerning in clients on diuretics like furosemide. Increased urine output (choice A) is an expected effect of diuretic therapy. Decreased appetite (choice B) is a common side effect but not as concerning as rapid weight loss. Blood pressure of 140/90 mm Hg (choice D) is slightly elevated but not the most concerning finding in a client being treated for congestive heart failure with furosemide.
A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?
- A. Blueberries
- B. Soybean oil
- C. Citrus fruits
- D. Green tea
Correct Answer: B
Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.