Nokea
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
- A. Acknowledge the frightening nature of the illness
- B. Delegate a back rub to the unlicensed assistive personnel
- C. Give simple explanations of what is happening
- D. Request a prescription for anti-anxiety medication
- E. Stay with the client and speak in a quiet, calm voice
Correct Answer: A,B,C,E
Rationale: Anxiety is common in PE. Acknowledging fears, delegating comfort measures like a back rub, providing simple explanations, and staying with the client in a calming manner are appropriate to reduce anxiety without routinely using medications, which may worsen hypoxia.
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When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
- A. Avoid drinking alcohol
- B. Eat more omega-3 fatty acids
- C. Exercise on a regular basis
- D. Maintain a healthy weight
- E. Stop smoking cigarettes
Correct Answer: C,D,E
Rationale: Hormonal birth control increases clotting risk. Health promotion measures to reduce PE risk include regular exercise, maintaining a healthy weight, and smoking cessation, as these address immobility, obesity, and smoking-related risks.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess the client for sedation needs
- B. Get family permission for restraints
- C. Provide frequent oral care per protocol
- D. Use nonverbal pain assessment tools
Correct Answer: C
Rationale: Frequent oral care is within the UAP's scope of practice and is essential for ventilated clients to prevent ventilator-associated pneumonia. The other tasks require nursing judgment and cannot be delegated.
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
- A. Assessing the client's platelet count
- B. Choosing an 18-gauge, 2-inch needle
- C. Not aspirating prior to injection
- D. Swabbing the injection site with alcohol
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously, requiring a smaller needle (e.g., 25"?26 gauge, 5/8 inch). An 18-gauge, 2-inch needle is inappropriate and could cause harm.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
A client on the emergency department has several broken ribs. What care measure will best promote comfort?
- A. Allowing the client to choose the position in bed
- B. Humidifying the supplemental oxygen
- C. Using the proper amount of water
- D. Providing warmed blankets
Correct Answer: A
Rationale: Allowing the client to choose a position of comfort (often upright) improves both comfort and oxygenation in clients with respiratory issues like broken ribs.